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Infectious Diseases

Question 56 of 180

A 3 year old boy is brought to the Emergency Department by his parents. They tell you he has had a fever for 3 days, associated with lethargy and anorexia. He is drinking well and passing good volumes of normal colour urine. On examination the child is sat quietly on mum's lap and is not responding normally to social cues. His observations recorded at triage are:

  • Heart rate: 150 beats per minute
  • Capillary refill: 2 seconds (central)
  • Respiratory rate: 40 breaths per minute
  • Oxygen saturations: 97% on air
  • Temperature: 38.6°C

Using the NICE "traffic light" system for paediatric fever, how would you classify this child?

Answer:

  • First, healthcare professionals should identify and manage any immediately life-threatening features, including compromise of the airway, breathing or circulation, and decreased level of consciousness.
  • If no life-threatening features are present, assess children with feverish illness for the presence or absence of symptoms and signs that can be used to predict the risk of serious illness using the traffic light system.
  • Measure and record temperature, heart rate, respiratory rate and capillary refill time as part of the routine assessment of a child with fever. Measure the blood pressure of children with fever if the heart rate or capillary refill time is abnormal and the facilities to measure blood pressure are available.
  • Assess children with fever for signs of dehydration. Look for: prolonged capillary refill time, abnormal skin turgor, abnormal respiratory pattern, weak pulse, cool extremities.
  • When assessing a child with feverish illness, enquire about recent travel abroad and consider the possibility of imported infections according to the region visited.

Paediatric Fever

Fever represents a regulated rise in body temperature, and an infant or child is generally considered to have a fever if their temperature is 38°C or higher in the literature. Measured and reported parental perception of fever should be accepted as a valid indicator of fever.

Measuring temperature

  • In infants under the age of 4 weeks, measure body temperature with an electronic thermometer in the axilla.
  • In children aged 4 weeks to 5 years, measure body temperature by one of the following methods: electronic thermometer in the axilla, chemical dot thermometer in the axilla or infra-red tympanic thermometer.
  • Do not routinely use the oral and rectal routes to measure the body temperature of children aged 0–5 years.

NICE traffic light system for assessment of child with fever

  • First, healthcare professionals should identify and manage any immediately life-threatening features, including compromise of the airway, breathing or circulation, and decreased level of consciousness.
  • If no life-threatening features are present, assess children with feverish illness for the presence or absence of symptoms and signs that can be used to predict the risk of serious illness using the traffic light system.
  • Measure and record temperature, heart rate, respiratory rate and capillary refill time as part of the routine assessment of a child with fever. Measure the blood pressure of children with fever if the heart rate or capillary refill time is abnormal and the facilities to measure blood pressure are available.
  • Assess children with fever for signs of dehydration. Look for: prolonged capillary refill time, abnormal skin turgor, abnormal respiratory pattern, weak pulse, cool extremities.
  • When assessing a child with feverish illness, enquire about recent travel abroad and consider the possibility of imported infections according to the region visited.
Assessment 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 or blue
Behaviour
  • Responding normally to social cues.
  • Content, smiling.
  • Stays awake or awakens quickly.
  • Strong normal cry or not crying.
  • Not responding normally to social cues.
  • Waking only with prolonged stimulation.
  • Decreased activity.
  • Not smiling.
  • 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.
Respiratory Normal
  • Nasal flaring.
  • Oxygen saturation ≤ 95% in air.
    Crackles in chest.
  •  Tachypnoea:
    • < 6 months: RR > 60
    • 6 - 12 months: RR > 50
    • > 1 year RR > 40
  • Grunting.
  • Moderate or severe chest indrawing.
  •  Tachypnoea
    • RR > 60
Hydration and circulation
  • Normal skin and eyes.
  • Moist mucous membranes.
  • Dry mucous membrane.
  • Poor feeding in infants.
  • CRT ≥ 3 seconds.
  • Reduced urine output.
  • Tachycardia:
    • < 1 year: HR > 160
    • 1 - 2 years: HR > 150
    • 2 - 5 years: HR > 140
  • Reduced skin turgor.
Other
  • None of the amber or red symptoms or signs.
  • Fever for ≥ 5 days.
  • Rigors
  • Temp ≥ 39°C in children 3 - 6 months.
  • Swelling of limb or joint.
  • Non-weight-bearing/not using an extremity.
  • Temp ≥ 38°C in children 0 - 3 months.
  • Non-blanching rash.
  • Bulging fontanelle.
  • Neck stiffness.
  • Status epilepticus.
  • Focal neurological signs.
  • Focal seizures.

Symptoms and signs suggestive of specific causes of fever

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 2mm in diameter (purpura)
    • CRT ≥ 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
  • Crackles in the chest
  • Nasal flaring
  • Chest drawing
  • Cyanosis
  • Oxygen saturation ≤ 95%
Urinary tract infection (< 3 months)
  • Vomiting
  • Poor feeding
  • Lethargy
  • Irritability
  • Abdominal pain or tenderness
  • Urinary frequency or dysuria
Septic arthritis/osteomyelitis
  • Swelling of a limb or a joint
  • Not using an extremity
  • Non-weight bearing
Kawasaki disease
  • Fever for 5 days or longer plus some of the following:
    • Bilateral conjunctival injection without exudate
    • Erythema and cracking of lips; strawberry tongue; or erythema of oral and pharyngeal mucosa
    • Oedema and erythema in the hands and feet
    • Polymorphous rash
    • Cervical lymphadenopathy

Management of the feverish child

In the prehospital setting:

  • If there are any immediately life-threatening features, including compromise of the airway, breathing, or circulation, or decreased level of consciousness, should be referred immediately for emergency medical care.
  • 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 paediatric specialist.
  • If any 'amber' features are present and no diagnosis has been reached, provide parents or carers with a 'safety net' or refer to specialist paediatric care for further 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.

In the hospital setting:

  • Children younger than 3 months with fever:
    • Perform FBC, CRP, blood culture, urine testing for UTI, chest x-ray (if respiratory signs are present), stool culture (if diarrhoea is present)
    • Perform lumbar puncture in infants younger than 1 month and in infants aged 1 - 3 months who appear unwell or who have a WCC < 5 x 10⁹/L or > 15 x 10⁹/L
    • Give parenteral antibiotics to:
      • infants younger than 1 month
      • infants aged 1 - 3 months who appear unwell
      • infants aged 1 - 3 months who have a WCC < 5 x 10⁹/L or > 15 x 10⁹/L
    • When parenteral antibiotics are indicated for infants younger than 3 months of age, a third-generation cephalosporin (for example cefotaxime or ceftriaxone) should be given plus an antibiotic active against listeria (for example, ampicillin or amoxicillin).
  • Children aged 3 months or older with fever without apparent source:
    • One or more 'red' features
      • Perform FBC, CRP, blood culture, urine testing for UTI
      • Consider lumbar puncture, chest x-ray, serum electrolyte and blood gas, as guided by clinical assessment
    • One or more 'amber' features
      • Perform urine testing for UTI, FBC, CRP, blood cultures
      • Consider LP for children younger than 1 year
      • Consider chest x-ray in a child with a fever greater than 39°C and WBC greater than 20 × 109/litre.
    • Green features
      • Perform urine testing for UTI and assess for symptoms and signs of pneumonia
      • Do not routinely perform blood tests and chest x-rays in children with fever who have no features of serious illness
    • In children aged 3 months or older with fever without apparent source, a period of observation in hospital (with or without investigations) should be considered as part of the assessment to help differentiate non-serious from serious illness. When a child has been given antipyretics, do not rely on a decrease or lack of decrease in temperature at 1–2 hours to differentiate between serious and non-serious illness.
  • Immediate treatment for children of all ages
    • Children with fever and shock presenting to specialist paediatric care or an emergency department should be:
      • given an immediate intravenous fluid bolus of 10 ml/kg; the initial fluid should normally be 0.9% sodium chloride
      • actively monitored and given further fluid boluses as necessary.
    • Give immediate parenteral antibiotics to children with fever presenting to specialist paediatric care or an emergency department if they are:
      • shocked
      • unrousable
      • showing signs of meningococcal disease
    • Immediate parenteral antibiotics should be considered for children with fever and reduced levels of consciousness.
    • In a child presenting to hospital with a fever and suspected serious bacterial infection, requiring immediate treatment, antibiotics should be directed against Neisseria meningitidis, Streptococcus pneumoniae, Escherichia coli, Staphylococcus aureus and Haemophilus influenzae type b. When parenteral antibiotics are indicated, a third-generation cephalosporin (for example, cefotaxime or ceftriaxone) should be given, until culture results are available. For children younger than 3 months, an antibiotic active against listeria (for example, ampicillin or amoxicillin) should also be given.
    • Give intravenous aciclovir to children with fever and symptoms and signs suggestive of herpes simplex encephalitis.
    • Oxygen should be given to children with fever who have signs of shock or oxygen saturation (SpO2) of less than 92% when breathing air. Treatment with oxygen should also be considered for children with an SpO2 of greater than 92%, as clinically indicated.
  • Antipyretic interventions
    • Antipyretic agents do not prevent febrile convulsions and should not be used specifically for this purpose.
    • Consider using either paracetamol or ibuprofen in children with fever who appear distressed.
    • Do not use antipyretic agents with the sole aim of reducing body temperature in children with fever.
    • When using paracetamol or ibuprofen in children with fever:
      • continue only as long as the child appears distressed
      • consider changing to the other agent if the child's distress is not alleviated
      • do not give both agents simultaneously
      • only consider alternating these agents if the distress persists or recurs before the next dose is due.

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  • Biochemistry
  • Blood Gases
  • Haematology
Biochemistry Normal Value
Sodium 135 – 145 mmol/l
Potassium 3.0 – 4.5 mmol/l
Urea 2.5 – 7.5 mmol/l
Glucose 3.5 – 5.0 mmol/l
Creatinine 35 – 135 μmol/l
Alanine Aminotransferase (ALT) 5 – 35 U/l
Gamma-glutamyl Transferase (GGT) < 65 U/l
Alkaline Phosphatase (ALP) 30 – 135 U/l
Aspartate Aminotransferase (AST) < 40 U/l
Total Protein 60 – 80 g/l
Albumin 35 – 50 g/l
Globulin 2.4 – 3.5 g/dl
Amylase < 70 U/l
Total Bilirubin 3 – 17 μmol/l
Calcium 2.1 – 2.5 mmol/l
Chloride 95 – 105 mmol/l
Phosphate 0.8 – 1.4 mmol/l
Haematology Normal Value
Haemoglobin 11.5 – 16.6 g/dl
White Blood Cells 4.0 – 11.0 x 109/l
Platelets 150 – 450 x 109/l
MCV 80 – 96 fl
MCHC 32 – 36 g/dl
Neutrophils 2.0 – 7.5 x 109/l
Lymphocytes 1.5 – 4.0 x 109/l
Monocytes 0.3 – 1.0 x 109/l
Eosinophils 0.1 – 0.5 x 109/l
Basophils < 0.2 x 109/l
Reticulocytes < 2%
Haematocrit 0.35 – 0.49
Red Cell Distribution Width 11 – 15%
Blood Gases Normal Value
pH 7.35 – 7.45
pO2 11 – 14 kPa
pCO2 4.5 – 6.0 kPa
Base Excess -2 – +2 mmol/l
Bicarbonate 24 – 30 mmol/l
Lactate < 2 mmol/l

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