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National Collaborating Centre for Women’s and Children’s Health (UK). Feverish Illness in Children: Assessment and Initial Management in Children Younger than 5 Years. London (UK): RCOG Press; 2007 May. (NICE Clinical Guidelines, No. 47.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

2Summary of recommendations

2.1. Key priorities for implementation (key recommendations)

Detection of fever

In children aged 4 weeks to 5 years, healthcare professionals should measure body temperature by one of the following methods:

Reported parental perception of a fever should be considered valid and taken seriously by health-care professionals. (3.3)

Clinical assessment of the child with fever

Children with feverish illness should be assessed 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 (Table 4.1). (4.4)

Table 4.1. Traffic light system for identifying risk of serious illness.

Table 4.1

Traffic light system for identifying risk of serious illness. Children with fever and any of the symptoms or signs in the ‘red’ column should be recognised as being at high risk. Similarly, children with fever and any of the symptoms or (more...)

Healthcare professionals should measure and record temperature, heart rate, respiratory rate and capillary refill time as part of the routine assessment of a child with fever. (4.5.2)

Management by remote assessment

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. (5.3)

Management by the non-paediatric practitioner

If any ‘amber’ features are present and no diagnosis has been reached, healthcare professionals should provide parents or carers with a ‘safety net’ or refer to specialist paediatric care for further assessment. The safety net should be one or more of the following:

  • providing the parent or carer with verbal and/or written information on warning symptoms and how further health care can be accessed (see Chapter 9)
  • arranging further follow-up at a specified time and place
  • liaising with other healthcare professionals, including out-of-hours providers, to ensure direct access for the child if further assessment is required. (6.3)

Oral antibiotics should not be prescribed to children with fever without apparent source. (6.5.1)

Management by the paediatric specialist

Infants younger than 3 months with fever should be observed and have the following vital signs measured and recorded:

  • temperature
  • heart rate
  • respiratory rate. (7.3)

Children with fever without apparent source presenting to paediatric specialists with one or more ‘red’ features should have the following investigations performed:

The following investigations should also be considered in children with ‘red’ features, as guided by the clinical assessment:

  • lumbar puncture in children of all ages (if not contraindicated)
  • chest X-ray irrespective of body temperature and white blood cell count (WBC)
  • serum electrolytes and blood gas. (7.4.1)

Antipyretic interventions

Antipyretic agents do not prevent febrile convulsions and should not be used specifically for this purpose. (8.3)

2.2. Summary of recommendations

Chapter 3 Thermometers and the detection of fever

The oral and rectal routes should not routinely be used to measure the body temperature of children aged 0–5 years. (3.2.1)

In infants under the age of 4 weeks, body temperature should be measured with an electronic thermometer in the axilla. (3.2.2)

In children aged 4 weeks to 5 years, healthcare professionals should measure body temperature by one of the following methods:

Healthcare professionals who routinely use disposable chemical dot thermometers should consider using an alternative type of thermometer when multiple temperature measurements are required. (3.2.2)

Forehead chemical thermometers are unreliable and should not be used by healthcare professionals. (3.2.2)

Reported parental perception of a fever should be considered valid and taken seriously by health-care professionals. (3.3)

Chapter 4 Clinical assessment of the child with fever

First, healthcare professionals should identify any immediately life-threatening features, including compromise of the airway, breathing or circulation, and decreased level of consciousness. (4.3)

Children with feverish illness should be assessed 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 (Table 4.1). (4.4)

Children with the following symptoms or signs should be recognised as being in a high-risk group for serious illness:

  • unable to rouse or if roused does not stay awake
  • weak, high-pitched or continuous cry
  • pale/mottled/blue/ashen
  • reduced skin turgor
  • bile-stained vomiting
  • moderate or severe chest indrawing
  • respiratory rate greater than 60 breaths/minute
  • bulging fontanelle
  • appearing ill to a healthcare professional. (4.5.1)

Children with any of the following symptoms should be recognised as being in at least an intermediate-risk group for serious illness:

  • wakes only with prolonged stimulation
  • decreased activity
  • poor feeding in infants
  • not responding normally to social cues/no smile
  • dry mucous membranes
  • reduced urine output
  • a new lump larger than 2 cm
  • pallor reported by parent or carer

Children who have all of the following features, and none of the high- or intermediate-risk features, should be recognised as being in a low-risk group for serious illness:

  • strong cry or not crying
  • content/smiles
  • stays awake
  • normal colour of skin, lips and tongue
  • normal skin and eyes
  • moist mucous membranes
  • normal response to social cues. (4.5.1)

Healthcare professionals should measure and record temperature, heart rate, respiratory rate and capillary refill time as part of the routine assessment of a child with fever. (4.5.2)

Healthcare professionals examining children with fever should be aware that a raised heart rate can be a sign of serious illness, particularly septic shock. (4.5.2)

A capillary refill time of 3 seconds or longer should be recognised as an intermediate-risk group marker for serious illness (‘amber’ sign). (4.5.2)

Healthcare professionals should 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. (4.5.2)

Height of body temperature alone should not be used to identify children with serious illness. However, children in the following categories should be recognised as being in a high-risk group for serious illness:

  • children younger than 3 months with a temperature of 38 °C or higher
  • children aged 3–6 months with a temperature of 39 °C or higher. (4.5.3)

Duration of fever should not be used to predict the likelihood of serious illness. (4.5.3)

Children with fever should be assessed for signs of dehydration. Healthcare professionals should look for:

Healthcare professionals should look for a source of fever and check for the presence of symptoms and signs that are associated with specific diseases (see Table 4.4). (4.6.1)

Table 4.4. Summary table for symptoms and signs suggestive of specific diseases.

Table 4.4

Summary table for symptoms and signs suggestive of specific diseases.

Meningococcal disease should be considered in any child with fever and a non-blanching rash, particularly if any of the following features are present:

  • an ill-looking child
  • lesions larger than 2 mm in diameter (purpura)
  • a capillary refill time of 3 seconds or longer
  • neck stiffness. (4.6.2)

Meningitis should be considered in a child with fever and any of the following features:

  • neck stiffness
  • bulging fontanelle
  • decreased level of consciousness
  • convulsive status epilepticus. (4.6.4)

Healthcare professionals should be aware that classical signs of meningitis (neck stiffness, bulging fontanelle, high-pitched cry) are often absent in infants with bacterial meningitis. (4.6.4)

Herpes simplex encephalitis should be considered in children with fever and any of the following features:

Pneumonia should be considered in children with fever and any of the following signs :

  • tachypnoea (respiratory rate greater than 60 breaths/minute, age 0–5 months; greater than 50 breaths/minute, age 6–12 months; greater than 40 breaths/minute, age older than 12 months)
  • crackles in the chest
  • cyanosis
  • oxygen saturation of 95% or less when breathing air. (4.6.6)

Urinary tract infection should be considered in any child younger than 3 months with fever.* (4.6.7)

Urinary tract infection should be considered in a child aged 3 months and older with fever and one or more of the following:*

  • vomiting
  • poor feeding
  • lethargy
  • irritability
  • abdominal pain or tenderness
  • urinary frequency or dysuria
  • offensive urine or haematuria. (4.6.7)

Septic arthritis/osteomyelitis should be considered in children with fever and any of the following signs:

  • swelling of a limb or joint
  • not using an extremity
  • non-weight bearing. (4.6.8)

Kawasaki disease should be considered in children with fever that has lasted longer than 5 days and who have four of the following five features:

  • bilateral conjunctival injection
  • change in mucous membranes in the upper respiratory tract (e.g. injected pharynx, dry cracked lips or strawberry tongue)
  • change in the extremities (e.g. oedema, erythema or desquamation)
  • polymorphous rash
  • cervical lymphadenopathy. (4.6.9)

Healthcare professionals should be aware that, in rare cases, incomplete/atypical Kawasaki disease may be diagnosed with fewer features. (4.6.9)

When assessing a child with feverish illness, healthcare professionals should enquire about recent travel abroad and should consider the possibility of imported infections according to the region visited. (4.7)

Chapter 5 Management by remote assessment

Healthcare professionals performing a remote assessment of a child with fever should seek to identify symptoms and signs of serious illness and specific diseases as described in Chapter 4 and summarised in Tables 4.1 and 4.4. (5.3)

Children whose symptoms or combination of symptoms suggest an immediately life-threatening illness (see Chapter 4) should be referred immediately for emergency medical care by the most appropriate means of transport (usually 999 ambulance). (5.3)

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. (5.3)

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 judgment of the healthcare professional carrying out the remote assessment. (5.3)

Children with ‘green’ features and none of the ‘amber’ or ‘red’ features can be managed at home with appropriate advice for parents and carers including advice on when to seek further attention from the healthcare services (see Chapter 9). (5.3)

Chapter 6 Management by the non-paediatric practitioner

Management by a non-paediatric practitioner should start with a clinical assessment as described in Chpater 4. Healthcare practitioners should attempt to identify symptoms and signs of serious illness and specific diseases as summarised in Tables 4.1 and 4.4. (6.2)

Children whose symptoms or combination of symptoms and signs suggest an immediately life-threatening illness (see Chapter 4) should be referred immediately for emergency medical care by the most appropriate means of transport (usually 999 ambulance). (6.3)

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. (6.3)

If any ‘amber’ features are present and no diagnosis has been reached, healthcare professionals should provide parents or carers with a ‘safety net’ or refer to specialist paediatric care for further assessment. The safety net should be one or more of the following:

  • providing the parent or carer with verbal and/or written information on warning symptoms and how further health care can be accessed (see Chapter 9)
  • arranging further follow-up at a specified time and place
  • liaising with other healthcare professionals, including out-of-hours providers, to ensure direct access for the child if further assessment is required. (6.3)

Children with ‘green’ features and none of the ‘amber’ or ‘red’ features can be managed at home with appropriate advice for parents and carers, including advice on when to seek further attention from the healthcare services (see Chapter 9). (6.3)

Children with symptoms and signs suggesting pneumonia who are not admitted to hospital should not routinely have a chest X-ray. (6.4)

Urine should be tested on children with fever as recommended in Urinary Tract Infection in Children.* (6.4)

Oral antibiotics should not be prescribed to children with fever without apparent source. (6.5.1)

Children with suspected meningococcal disease should be given parenteral antibiotics at the earliest opportunity (either benzylpenicillin or a third-generation cephalosporin). (6.5.2)

Chapter 7 Management by the paediatric specialist

Management by the paediatric specialist should start with a clinical assessment as described in Chapter 4. The healthcare professional should attempt to identify symptoms and signs of serious illness and specific diseases as summarised in Tables 4.1 and 4.4. (7.2)

Infants younger than 3 months with fever should be observed and have the following vital signs measured and recorded:

  • temperature
  • heart rate
  • respiratory rate. (7.3)

Infants younger than 3 months with fever should have the following investigations performed:

  • full blood count
  • blood culture
  • C- reactive protein
  • urine testing for urinary tract infection*
  • chest X-ray only if respiratory signs are present
  • stool culture, if diarrhoea is present. (7.3)

Lumbar puncture should be performed on the following children (unless contraindicated):

  • infants younger than 1 month
  • all infants aged 1–3 months who appear unwell
  • infants aged 1–3 months with white blood cell count (WBC) less than 5 × 109/litre or greater than 15 × 109/litre. (7.3)

When indicated, a lumbar puncture should be performed without delay and, whenever possible, before the administration of antibiotics. (7.3)

Parenteral antibiotics should be given to:

  • infants younger than 1 month
  • all infants aged 1–3 months who appear unwell
  • infants aged 1–3 months with WBC less than 5 × 109/litre or greater than 15 × 109/litre. (7.3)

When parenteral antibiotics are indicated for infants less than 3 months of age, a third-generation cephalosporin (e.g. cefotaxime or ceftriaxone) should be given plus an antibiotic active against listeria (e.g. ampicillin or amoxicillin). (7.3)

Children with fever without apparent source presenting to paediatric specialists with one or more ‘red’ features should have the following investigations performed:

The following investigations should also be considered in children with ‘red’ features, as guided by the clinical assessment:

  • lumbar puncture in children of all ages (if not contraindicated)
  • chest X-ray irrespective of body temperature and white blood cell count (WBC)
  • serum electrolytes and blood gas. (7.4.1)

Children with fever without apparent source presenting to paediatric specialists who have one or more ‘amber’ features should have the following investigations performed unless deemed unnecessary by an experienced paediatrician.

  • urine should be collected and tested for urinary tract infection*
  • blood tests: full blood count, C- reactive protein and blood cultures
  • lumbar puncture should be considered for children younger than 1 year
  • chest X-ray in a child with a fever greater than 39 °C and white blood cell count (WBC) greater than 20 × 109/litre. (7.4.1)

Children who have been referred to a paediatric specialist with fever without apparent source and who have no features of serious illness (that is, the ‘green’ group), should have urine tested for urinary tract infection* and be assessed for symptoms and signs of pneumonia. (7.4.1)

Routine blood tests and chest X-rays should not be performed on children with fever who have no features of serious illness (that is, the ‘green’ group). (7.4.1

Febrile children with proven respiratory syncytial virus or influenza infection should be assessed for features of serious illness. Consideration should be given to urine testing for urinary tract infection.* (7.4.2)

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 an assessment to help differentiate non-serious from serious illness. (7.4.3)

When a child has been given antipyretics:

  • healthcare professionals should not rely on a decrease or lack of decrease in temperature after 1–2 hours to differentiate between serious and non-serious illness
  • children in hospital with ‘amber’ or ‘red’ features should be reassessed after 1–2 hours. (7.4.4)

Children with fever and shock presenting to specialist paediatric care or an emergency department should be:

  • given an immediate intravenous fluid bolus of 20 ml/kg; the initial fluid should normally be 0.9% sodium chloride
  • actively monitored and given further fluid boluses as necessary. (7.5)

Children with fever presenting to specialist paediatric care or an emergency department should be given immediate parenteral antibiotics if they are:

Immediate parenteral antibiotics should be considered for children with fever and reduced levels of consciousness. In these cases symptoms and signs of meningitis and herpes simplex encephalitis should be sought (see Table 4.4). (7.5.3)

When parenteral antibiotics are indicated, a third-generation cephalosporin (e.g. cefotaxime or ceftriaxone) should be given, until culture results are available. For children younger than 3 months, an antibiotic active against listeria (e.g. ampicillin or amoxicillin) should also be given. (7.5.3)

Children with fever and symptoms and signs suggestive of herpes simplex encephalitis should be given intravenous aciclovir. (7.5.4)

Oxygen should be given to children with fever who have signs of shock or oxygen saturation (SpO2) of less than 92% when breathing air. (7.5.5)

Treatment with oxygen should also be considered for children with an SpO2 of greater than 92%, as clinically indicated. (7.5.5)

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. A third-generation cephalosporin (e.g. cefotaxime or ceftriaxone) is appropriate, until culture results are available. For infants younger than 3 months, an antibiotic active against listeria (e.g. ampicillin or amoxicillin) should be added. (7.6)

Healthcare professionals should refer to local treatment guidelines when rates of bacterial antibiotic resistance are significant. (7.6)

In addition to the child’s clinical condition, healthcare professionals should consider the following factors when deciding whether to admit a child with fever to hospital:

  • social and family circumstances
  • other illnesses that affect the child or other family members
  • parental anxiety and instinct (based on their knowledge of their child)
  • contacts with other people who have serious infectious diseases
  • recent travel abroad to tropical/subtropical areas, or areas with a high risk of endemic infectious disease
  • when the parent or carer’s concern for their child’s current illness has caused them to seek healthcare advice repeatedly
  • where the family has experienced a previous serious illness or death due to feverish illness which has increased their anxiety levels
  • when a feverish illness has no obvious cause, but the child remains ill longer than expected for a self-limiting illness. (7.7)

If it is decided that a child does not need to be admitted to hospital, but no diagnosis has been reached, a safety net should be provided for parents and carers if any ‘red’ or ‘amber’ features are present. The safety net should be one or more of the following:

  • providing the parent or carer with verbal and/or written information on warning symptoms and how further health care can be accessed (see Chapter 9)
  • arranging further follow-up at a specified time and place
  • liaising with other healthcare professionals, including out-of-hours providers, to ensure direct access for the child if further assessment is required. (7.7)

Children with ‘green’ features and none of the ‘amber’ or ‘red’ features can be managed at home with appropriate advice for parents and carers, including advice on when to seek further attention from the healthcare services (see Chapter 9). (7.7)

Children with fever who are shocked, unrousable or showing signs of meningococcal disease should be urgently reviewed by an experienced paediatrician and consideration given to referral to paediatric intensive care. (7.8)

Children with suspected meningococcal disease should be given parenteral antibiotics at the earliest opportunity (either benzylpenicillin or a third-generation cephalosporin). (7.9).

Children admitted to hospital with meningococcal disease should be under paediatric care, supervised by a consultant and have their need for inotropes assessed. (7.9)

Chapter 8 Antipyretic interventions

Tepid sponging is not recommended for the treatment of fever. (8.2.1)

Children with fever should not be underdressed or over-wrapped. (8.2.1)

The use of antipyretic agents should be considered in children with fever who appear distressed or unwell. Antipyretic agents should not routinely be used with the sole aim of reducing body temperature in children with fever who are otherwise well. The views and wishes of parents and carers should be taken into consideration. (8.2.2).

Either paracetamol or ibuprofen can be used to reduce temperature in children with fever. (8.2.2)

Paracetamol and ibuprofen should not be administered at the same time to children with fever. (8.2.3)

Paracetamol and ibuprofen should not routinely be given alternately to children with fever. However, use of the alternative drug may be considered if the child does not respond to the first agent. (8.2.3)

Antipyretic agents do not prevent febrile convulsions and should not be used specifically for this purpose. (8.3)

Chapter 9 Advice for home care

Parents or carers should be advised to manage their child’s temperature as described in Chapter 8. (9.2)

Parents or carers looking after a feverish child at home should be advised:

  • to offer the child regular fluids (where a baby or child is breastfed the most appropriate fluid is breast milk)
  • how to detect signs of dehydration by looking for the following features:
    • – sunken fontanelle
    • – dry mouth
    • – sunken eyes
    • – absence of tears
    • – poor overall appearance
  • to encourage their child to drink more fluids and consider seeking further advice if they detect signs of dehydration
  • how to identify a non-blanching rash
  • to check their child during the night
  • to keep their child away from nursery or school while the child’s fever persists but to notify the school or nursery of the illness. (9.2)

Following contact with a healthcare professional, parents and carers who are looking after their feverish child at home should seek further advice if:

  • the child has a fit
  • the child develops a non-blanching rash
  • the parent or carer feels that the child is less well than when they previously sought advice
  • the parent or carer is more worried than when they previously sought advice
  • the fever lasts longer then 5 days
  • the parent or carer is distressed, or concerned that they are unable to look after their child. (9.3)

2.3. Research recommendations

Measuring temperature in young babies: tympanic versus axilla electronic versus axilla chemical dot versus temporal artery. (3.2.2)

A study to confirm normal ranges for heart rate at various body temperatures and to determine whether children with heart rates outside these ranges are at higher risk of serious illness. (4.5.2.1)

There is a need for a prospective study to assess the prognostic value of symptoms such as limb pain and cold hands and feet that have been identified as possible early markers of meningococcal disease. (4.6.2)

The GDG recommends that a UK study is undertaken to determine the validity of symptoms reported on remote assessment for children with fever. (5.3)

The GDG recommends that research is carried out on referral patterns between primary and secondary care for children with fever, so the health economic impact of this and future guidelines can be estimated. (6.3)

The GDG recommends that a UK study of the performance characteristics and cost-effectiveness of procalcitonin versus C-reactive protein in identifying serious bacterial infection in children with fever without apparent source be carried out. (7.4.1)

The GDG recommends that studies are conducted in primary care and secondary care to determine whether examination or re-examination after a dose of antipyretic medication is of benefit in differentiating children with serious illness from those with other conditions. (7.4.4)

The GDG recommends that studies are conducted on the effectiveness of physical methods of attempting to reduce fever, for example lowering ambient temperature, fanning and cold oral fluids. (8.2.1)

Efficacy and cost-effectiveness studies are required which measure symptom relief associated with fever relief. (8.2.2)

The GDG recommends that a study is conducted on the effectiveness and safety of alternating doses of paracetamol and ibuprofen in reducing fever in children who remain febrile after the first antipyretic. (8.2.3)

Footnotes

*

See Urinary Tract Infection in Children, NICE clinical guideline (publication expected August 2007).

Copyright © 2007, National Collaborating Centre for Women’s and Children’s Health.

No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK [www.cla.co.uk]. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

Cover of Feverish Illness in Children
Feverish Illness in Children: Assessment and Initial Management in Children Younger than 5 Years.
NICE Clinical Guidelines, No. 47.
National Collaborating Centre for Women’s and Children’s Health (UK).
London (UK): RCOG Press; 2007 May.

NICE (National Institute for Health and Care Excellence)

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