Feverish Illness in Children (< 5 years), Paediatrics (461)

November 2023: This guidance is currently under review as it has gone beyond the standard review date. It reflects best practice at the time of authorship / last review and remains safe for use. If there are any concerns regarding the content then please consult with senior clinical staff to confirm.

Introduction

Feverish illness is a common occurrence in childhood. It is the most frequent reason for parents to consult a doctor about their child, and is the second most common cause of hospital admission in childhood.¹ Most are self-limiting, however despite this, infections are the most common cause of death in those aged less than 5 years.¹ Therefore it is important to identify those with potentially severe infections and initiate treatment rapidly.

Definition

Feverish Illness is diagnosed in all children (<5years) who present with a temperature over 38°C as measured by the following as advised by NICE guidelines¹

In those <4weeks of age – electronic thermometer placed in axilla
In those >4 weeks of age
- Chemical dot in axilla
- Electronic thermometer in axilla
- Infra-red tympanic thermometer
In addition this includes those children who have no recorded fever at triage or assessment but whose parents report fever at home
- regular temperatures should be taken whilst in the ED to monitor for this

Triage

Observations

All children who present with fever/parental reports of fever at home should have the following recorded at triage¹

HR
BP (if HR is recorded as abnormal)
RR
Oxygen saturations
Temperature
CRT (centrally and peripherally)
Presence of a non-blanching rash
History of recent foreign travel recorded
Immunisation history

In addition, parents should be given urine kit, and asked to collect sample for analysis.

Those children who have any ABC compromise, appear ill to health care professional, or have markedly deranged physiology should be taken immediately to the resuscitation area and a senior doctor should be involved. Treat according to APLS guidance ^1,2

The remaining children should continue to be triaged appropriately and if pyrexia is present, one anti-pyretic agent should be administered if not already done so prior to presentation, doses of which can be found in the BNFc³

Clinical assessment

If ABC compromise/ill looking child/markedly deranged physiology the child should be taken to resus and managed according to APLS guidance²

The following should be assessed and documented in all feverish children¹

History of illness and any features of specific disease (e.g. tonsillitis, UTI)
Full examination of child including ENT, inspection of all joints, hernial orifices and exposure of all skin areas.
Hydration and circulation status – CRT, extremity temperatures, presence of peripheral pulses, skin turgor, mucus membranes
Appearance of skin (e.g. mottled, pale, pink)
Activity levels
Respiratory pattern
Signs of severe illness (non-blanching rash, prolonged fever, neurological signs)

These children should then be assigned to a colour group in keeping with the NICE guidance on feverish children” 2013’s traffic light system¹. This will help determine further management.

Children will be classified into either into GREEN, AMBER or RED groups depending on their clinical assessment.¹ Re-assess the child once anti-pyretic medications have been administered as this may alleviate some clinical features and the child may be grouped into a lower severity group.

Assessment table divided by colour

Figure 1: Table taken from NICE Clinical Guideline 160 - Feverish illness in children 2013.

Management

Children under 1 month

ALL children under 1 month of age with a documented fever >38° or those that appear unwell should undergo a full septic screen which should consist of:

Bloods including blood cultures
Urine microscopy, culture and sensitivity
LP*
CXR

IV antibiotics should be given in accordance with local guidelines.

*Please see RHSC lumbar puncture guideline for contraindications to LP

Children under 3 months of age¹

with documented fever in ED
OR
apyrexial on assessment but who have parental reports of fever at home
OR
no documented fever but appear unwell on examination

in whom no apparent source is found, the following investigations are advised^1, and the patient should be admitted under medical paediatrics.

FBC
Blood Culture
CRP
Urinalysis and CSU
CXR on clinical judgement
LP* should be performed on the majority of children in this age group, unless there is a clear reason not to do so and this has been discussed with a senior clinician.

Administer IV antibiotics (refer to local guidance) if

1-3months who appear unwell
If WCC <5x10⁹/L or >15x109/L

In addition, children <3 months who have fever with a clear source should be discussed with the ED consultant on duty or medical registrar out of hours for admission to CDU or ARU for an extended period of monitoring +/- further investigation.

Children > 3 months of age¹

if a source is identified then management should be directed towards that specific illness
If no source is found then management should be directed as per NICE traffic light system, described below¹

RED¹
Investigations¹ FBC Blood culture CRP Urinalysis and CCU On clinical judgement LP CXR U&E Venous gas Admission under medical paediatrics	IMPORTANT: These children are likely to be septic, and should be managed with the early input of a senior clinician and early administration of IV antibiotics considered.

AMBER¹
Investigations¹ FBC Culture CRP Urinalysis and CCU On clinical judgement LP (in particular if <1 year) CXR (if fever >39C and WCC >20X10⁹/L If a child remains in the amber category after a period of observation in the ED they should be referred to medical paediatrics.

GREEN¹

Urinalysis and CCU
- If <1 year or previous history of UTI then wait for urinalysis in ED/CDU
- If >1 year and no history of previous UTI the urine sample can be collected at home and handed into GP.
As per ED guidance, any child with an abnormality of their triage observations should have a minimum of one further set of observations recorded on a CEWS chart. If the child remains in the green category and there is no additional clinical concern they can be discharged with written advice.

Disposition

Children with a clear source of infection should be treated appropriately as per local guidance specific to that febrile illness, with written and verbal advice given to parents.

Children in the green category with no clear cause of pyrexia may be discharged home after assessment and appropriate investigations are completed. There should be a responsible adult at home and parental anxiety should be addressed.

Children not deemed suitable for discharge home after ED assessment should be admitted either to the CDU or directly to the ARU, following discussion with the senior doctor on the ED floor.

Advice sheet for parents

Advice sheet for parents (pdf):

Discharge advice for carers of children younger than 5 years who have a fever of an unknown cause ENGLISH

Discharge advice for carers of children younger than 5 years who have a fever of an unknown cause ARABIC

Discharge advice for carers of children younger than 5 years who have a fever of an unknown cause ROMANIAN

Discharge advice for carers of children younger than 5 years who have a fever of an unknown cause SIMPLIFIED CHINESE

Last reviewed: 23/10/2018

Next review date: 30/04/2024

Author(s): Marie Spiers.

Version: 2

Approved By: Paediatric Clinical Effectiveness & Risk Committee

References

National Institute for Health and Care Excellence (2013) Feverish illness in children. [160]. London: National Institute for Health and Care Excellence
Advanced Paediatric Life Support The Practical Approach (2005) 5^th Edition, ALSG group. Wiley and Sons, Oxford.
Joint Formulary Committee British National Formulary For Children. 55th Ed., London: British Medical Association and Royal Pharmaceutical Society of Great Britain. Joint Formulary Committee (2013) British National Formulary.