Introduction
- Assessment must differentiate the well child from the unwell child, while identifying the source of infection where possible
- All children under 28 days require investigations (FBC, U&E, CRP, blood, urine and CSF cultures) and admission for IV antibiotics
- All children between 1-3 months old require a senior review, with investigations based on senior assessment and subsequent admission under paediatrics
Definition of fever
- Temperature of 38°C and above
- Use an axillary thermometer in infants (under 12 months)
- Use a tympanic thermometer in children over 12 months
Clinical
Vital components of History
- Localising symptoms
- Duration of fever
- Travel
- Regular & current meds (i.e. partially treated meningitis with oral antibiotics)
- High risk past Hx: prematurity, chronic lung disease, cardiac malformation, immunosuppression, previous sepsis, indwelling devices
- Immunization status
Key components of physical exam.
Step 1: Differentiate the well v unwell child
| Colour | Pallor* (including parent/carer report) Mottled Blue/Cyanosed |
|---|---|
| Activity | Lethargy or decreased activity* Not responding normally to social cues Does not wake or only with prolonged stimulation, or if roused, does not stay awake Weak, high-pitched or continuous cry |
| Respiratory | Grunting Tachypnoea Increased work of breathing Hypoxia |
| Circulation and Hydration | Poor feeding* Dry mucous membranes Persistent tachycardia Central CRT ≥3 seconds Reduced skin turgor Reduced urine output |
| Neurological | Bulging fontanelle Neck stiffness Focal neurological signs Focal, complex or prolonged seizures |
| Other | Non-blanching rash Fever for ≥5 days Swelling of a limb or joint Non-weight bearing/not using an extremity |
Pallor, poor feeding or decreased activity on their own may not suggest a seriously unwell child. Adapted from: Feverish illness in children NICE guideline 2019.
Step 2: Localizing the source of infection
- ENT exam.: including assessment of cervical lymph nodes
- Neuro exam.: GCS, fontanelles, gait, meningism: kernig's & Brudzinski signs
- NB: Signs of meningism are unreliable in children under 60 days
- Cardiac exam.: Assess for murmurs & bilateral femoral pulses
- Resp exam.: Assess for wheeze or focal crackles
- GI/GU exam.: Assess for abdo./flank tenderness, organomegaly and bowel sounds
- MSK exam.: Assess all joints, looking for osteomyelitis/septic arthritis
Investigations
Consider sending a urine for culture and microscopy if:
- All febrile infants under 3 months
- Fever 24-48 hours in children < 12 months or Hx of UTI
- Fever >48 hours with no clear focus or preverbal children
Extra points:
- Do not rely on point of care dipstick
- If a child is well, it is reasonable to discharge on the advice that parents return a sample to the GP
- However, a child who has not produced urine in the past 6 hours should not be discharged from the ED until they do so
- Stool sample for culture, if diarrhoea present > 7 days or evidence of blood or mucous in stool
- Bloods should only be ordered if they will change Mx. (low yield apart from blood cultures)
- Pneumonia is a clinical diagnosis. CXR should only be requested if it will change management (e.g. suspected empyema)
Management
a) the well child
- Treat the source of infection
- Can be discharged while febrile, once vital signs are normal
- Viral illness can present without an obvious focus and GP follow up can be arranged within 48 hours if otherwise well
- Recommend one antipyretic (paracetamol or ibuprofen), unless treating a painful condition such as tonsillitis
- Avoid aspirin due to risk of Reye's syndrome
b) the unwell child
- Seek early senior advice
- Commence resuscitation and appropriate antibiotic therapy
- Admit
c) Fever in children <3 months
- Always suspect CNS infection, even when an alternative source of infection has been identified
- Full septic work-up should be commenced, including lumbar puncture (LP may be deferred in a well infant >28 days if there is a clear focus of infection e.g. UTI, and senior advice has been sought)
- Liaise early with Paed. Reg. on call
d) fever > 7 days
- Seek senior advice
- May require full septic screen
- Be alert for signs of kawasaki disease
Discharge Rules
- Child's vital signs must be within normal range, although it is reasonable to discharge a febrile child who is otherwise well
- Child must be walking and talking (age appropriate)
- Child must look well (i.e. non toxic)
- Child must be tolerating oral fluids and have passed urine within the past 6 hours
- Always provide a parental information leaflet prior to discharge