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
Infectious Diseases
Last Updated: 2nd March 2023
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 |
|
|
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| Behaviour |
|
|
|
| Respiratory | Normal |
|
|
| Hydration and circulation |
|
|
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| Other |
|
|
|
Symptoms and signs suggestive of specific causes of fever
| Diagnosis to be considered | Symptoms and signs in conjunction with fever |
|---|---|
| Meningococcal disease |
|
| Bacterial meningitis |
|
| Herpes simplex encephalitis |
|
| Pneumonia |
|
| Urinary tract infection (< 3 months) |
|
| Septic arthritis/osteomyelitis |
|
| Kawasaki disease |
|
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.
- One or more 'red' features
- 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.
- Children with fever and shock presenting to specialist paediatric care or an emergency department should be:
- 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 |
