NHS Patient information Fever in children

CKS Feverish children

Definition

An infant or child is generally considered to have a fever if their temperature is 38°C or higher.

Temperature measurement

Measured and reported parental perception of fever should be accepted as a valid indicator of fever.

<4w: electronic thermometer in the axilla.

4w- age 5y: axilla (electronic or chemical dot thermometer) OR infra-red tympanic thermometer.

DO NOT USE forehead thermometers or the oral/rectal route to measure temperature.

History

1. Any associated symptoms suggesting an underlying cause of fever.

2. Any perinatal complications such as maternal fever and/or premature delivery.

3. Any significant medical conditions, such as known immunosuppression or immunodeficiency.

4. Any recent antipyretic drug and/or antibiotic use.

5. The child's immunization history, and any missed immunizations. See the CKS topic on Immunizations - childhood for more information.

6. Any recent foreign travel, including to areas with a high risk of endemic infectious disease such as malaria. See the CKS topic on Malaria for more information.

7. Any recent contact with people with serious infectious diseases.

8. Parental/carer health beliefs about fever and previous family experience of serious febrile illness (may increase parent/carer anxiety).

Assess

• general appearance

• temperature

• heart rate

• respiratory rate

• signs of dehydration
  prolonged capillary refill time ≥ 3s
  cool extremities
  abnormal skin turgor
  decreased urine output/wet nappies

• blood pressure (if equipment available)

• urine dipstick analysis and urine microscopy and culture if there is unexplained fever and no apparent focus of infection to exclude a UTI.

 NICE 'traffic light' system: child will fall into AMBER or RED risk if they have any of the relevant clinical features.
The management of children with fever should be directed by the level of risk

GREEN

Normal colour of skin, lips, and tongue

Responding normally to social cues.
Content and smiling.
Stays awake or awakens quickly.
Strong normal cry or not crying.

No respiratory compromise

Normal skin turgor and eyes.
Moist mucous membranes.

None of the amber or red symptoms or signs

AMBER

Pallor of skin, lips, or tongue

Not responding normally to social cues.
Waking only with prolonged stimulation.
Decreased activity. Not smiling.

Nasal flaring.Tachypnoea:
6–12 months of age RR > 50
> 12 months of age RR > 40
Oxygen saturation  ≤ 95%.
Crackles on chest auscultation.

Poor feeding in infants.
Dry mucous membranes.
Capillary refill time ≥ 3s
Reduced urine output (in infants ask about wet nappies).
Tachycardia: 
>160 age <1yr 
>150  age 1–2y
>140  age 2–5y

Fever for 5 days or more. Rigors.
Temperature ≥ 39°C in age 3m-6m.

Swelling of limb or joint.
Non weight-bearing or not using a limb.

RED

Pale, mottled, ashen, or blue skin, lips, or tongue.

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 crying

Grunting, Tachypnoea:
RR> 60
Moderate or severe chest indrawing

Reduced skin turgor

Temperature ≥ 38°C in age 0-3m
Non-blanching rash
Bulging fontanelle
Neck stiffness
Focal neurological signs
Focal seizures
Status epilepticus

RED features (serious or life-threatening, high risk of serious illness): call 999—-> ambulance transfer to hospital A&E

1. If there is any compromise of the airway, breathing, circulation, or consciousness level

2. Features of SEPSIS or central nervous system infection, such as bacterial meningitis/meningococcal disease or encephalitis.

3. Features of pneumonia

4. Evidence of severe dehydration

AMBER features (intermediate risk of serious illness) —> paediatric specialist review (urgency to be decided)

1. Age <3 months with a suspected urinary tract infection (UTI) and no alternative focus of infection, to obtain a reliable urine specimen and initiate treatment.

2. The feverish illness has no obvious underlying cause, and the child is unwell for longer than expected for a self-limiting illness.

3. There is significant parental/carer anxiety and/or difficulty coping due to the family/social situation.

GREEN features (low risk of serious illness)—> child can usually be managed at home

SPECIFIC PYREXIA INDUCING DISEASES

Meningococcal disease

Non-blanching rash
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
High-pitched cry

Herpes simplex encephalitis

Focal neurological signs
Focal seizures
Decreased level of consciousness

Pre-hospital management of suspected bacterial meningitis and meningococcal septicaemia

1. Transfer children and young people with suspected bacterial meningitis or suspected meningococcal septicaemia to secondary care as an emergency by telephoning 999.

Suspected bacterial meningitis without non-blanching rash

Transfer children directly to secondary care without giving parenteral antibiotics.
However, if urgent transfer to hospital is not possible, administer antibiotics.

Suspected meningococcal disease (meningitis with non-blanching rash or meningococcal septicaemia)

Give parenteral antibiotics (intramuscular or intravenous benzylpenicillin) at the earliest opportunity, but do not delay urgent transfer to hospital to give the parenteral antibiotics.

Withhold benzylpenicillin only in children and young people who have a clear history of anaphylaxis after a previous dose (if this is the case, use cefotaxime). A history of a rash following penicillin is not a contraindication.

Doses of i.v. or i.m benzylpenicillin prior to urgent transfer to hospital
Children younger than 1 year of age: 300 mg
Children 1–9 years of age: 600 mg
Children >10y: 1.2 g

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

Consider urinary tract infection in any child younger than 3 months with fever.
Other symptoms:
Vomiting
Poor feeding
Lethargy
Irritability
Abdominal pain or tenderness
Urinary frequency or dysuria

Septic arthritis or osteomyelitis

Swelling of a limb or joint
Not using an extremity
Non-weight bearing

Kawasaki disease

1. Fever ≥38°C or higher, for 5 days or longer

2. Bilateral conjunctival injection without exudate.

3. Erythema and cracking of lips; strawberry tongue

4. Erythema of oral and pharyngeal mucosa.

5. Oedema and erythema and desquamation of the skin of the hands and feet.

6. Polymorphous rash (especially on the chest).

7. Cervical lymphadenopathy.

8. Treatment with aspirin and intravenous immunoglobulin IVIG therapy.

Imported infections

When assessing a child with feverish illness, enquire about recent travel abroad and consider the possibility of imported infections according to the region visited.

Management

1. Assess the risk of a serious illness in all children with a fever using the NICE 'traffic light' system.

2. Do not prescribe oral antibiotics to febrile children without an apparent focus of infection.

3. Give paracetamol or ibuprofen if the child is uncomfortable or distressed.
   Consider switching to ibuprofen if paracetamol alone is ineffective, and vice versa, but not giving both agents simultaneously.
   Consider alternating these agents if paracetamol monotherapy and ibuprofen monotherapy are ineffective
   Use ibuprofen with caution if the child is dehydrated and hypovolaemic, due to the increased risk of renal impairment.

4. Not to use aspirin as an antipyretic (risk of Reye syndrome)

5. Not to use routine prophylactic antipyretic drugs to reduce or prevent recurrent febrile seizures.

6. When a child has been given antipyretics, do not rely on a decrease or lack of decrease in temperature to differentiate between serious and non-serious illness

7. Monitor the child:
   Looking for signs of dehydration in the child.
   Offer regular fluids
   Keeping the child away from nursery or school until they are recovered.

8. Safety netting advice

   Arrange urgent medical review if:

• The child shows respiratory compromise: grunting, fast breathing rate, marked chest indrawing, apnoeas, central cyanosis, exhaustion

• The child shows impaired circulation/dehydration: reduced skin turgor, fluid intake 50-75% of normal (or no wet nappy for 12 hours)

• The child shows impaired neurology: does not wake if roused, seizure, neck stiffness, develops a non-blanching rash

• The child shows features of serious sepsis: persisting fever

• The parents are concerned and unable to look after the infant or child at home.

Management by remote assessment (for example, telephone calls to NHS 111)

Children whose symptoms suggest an immediately life-threatening illness should be referred immediately for emergency medical care by the most appropriate means of transport (usually 999 ambulance).

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 2 hours.

Children with 'amber' but no 'red' features should be assessed by a healthcare professional in a face-to-face setting.
The urgency of this assessment should be determined by the clinical judgement of the healthcare professional carrying out the remote assessment.

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

Antipyretic drug dosage regimes

Oral paracetamol (standard single dose)

• Age 1 to 2 months: 30–60 mg every 8 hours as required; maximum 60 mg/kg per day (off-label indication).

• Age 3 to 5 months: 60 mg. Doses may be repeated every 4–6 hours if necessary (maximum of 4 doses in 24 hours).

• Age 6 months to 1 year: 120 mg.

• Age 2 to 3 years: 180 mg.

• Age 4 to 5 years: 240 mg.

• Age 6 to 7 years: 240–250 mg.

• Age 8 to 9 years: 360–375 mg.

• Age 10 to 11 years: 480–500 mg.

• Age 12 to 15 years: 480–750 mg.

• Age 16 years: 500 mg to 1 gram.

Oral ibuprofen (standard single dose if age>3 months)

Age 1 to 2 months: 5 mg/kg 3–4 times a day (off-label indication under 3 months of age or bodyweight less than 5 kg).

Age 3 to 5 months: 50 mg three times a day (maximum daily dose to be given in 3–4 divided doses; maximum 30 mg/kg per day).

Age 6 to 11 months: 50 mg three to four times a day (maximum daily dose to be given in 3–4 divided doses; maximum 30 mg/kg per day).

Age 1 to 3 years: 100 mg three times a day (maximum daily dose to be given in 3–4 divided doses; maximum 30 mg/kg per day).

Age 4 to 6 years: 150 mg three times a day (maximum daily dose to be given in 3–4 divided doses; maximum 30 mg/kg per day).

Age 7 to 9 years: 200 mg three times a day (maximum daily dose to be given in 3–4 divided doses; maximum 30 mg/kg per day; maximum 2.4 g per day).

Age 10 to 11 years: 300 mg three times a day (maximum daily dose to be given in 3–4 divided doses; maximum 30 mg/kg per day; maximum 2.4 g per day).

Age 12 to 16 years: initially 300–400 mg 3–4 times a day (increased if necessary up to 600 mg 4 times a day; maintenance 200–400 mg 3 times a day may be adequate).