Clinical Practice Guidelines

Febrile child

  • See also:

    Antibiotic Guidelines
    CSF Interpretation
    Lumbar Puncture Guideline
    Suprapubic Aspirate Guideline

    Background to condition:

    • Since the introduction of the pneumococcal vaccine the rate of occult bacteraemia has fallen to <1% in healthy, immunised infants. E.coli and Staphylococcus aureus are now frequently isolated organisms.
    • The following are not good predictors of serious illness: degree of the fever, its rapidity of onset, its response to antipyretics, febrile convulsions.
    • Ideally, health care workers should use the same body site and the same type of thermometer when measuring temperatures:
      • Axillary temperatures: Readings are lower than measurements from other sites. For an accurate reading, the thermometer must be placed over the axillary artery.
      • Tympanic temperatures: For an accurate measurement the pinna needs to be retracted to straighten the external auditory meatus and the instrument should be directed at the tympanic membrane.
      • Skin temperatures: Measurements can be taken from the forehead or axilla. Ambient temperature may affect readings.
      • Rectal temperatures: Often used as the reference standard for temperature measurements. In neonates, screen first with axillary temperature then consider performing a rectal temperature if a fever is still suspected.

    Teething will not cause fever > 38.5oC

    Remember that in babies under 3 months of age hypothermia or temperature instability can be signs of serious bacterial infection (or other serious illness)

    Assessment

    Features on history:

    • Localising symptoms: cough, coryza, headache, photophobia, diarrhoea, vomiting, abdominal pain, joint symptoms
    • Travel history
    • Sick contacts
    • Immunisation hx

    Features on examination:

    • General aspects of the child's behaviour and appearance provide the best indication of whether a serious infection is likely -   Screening tool for young children presenting with acute febrile illness.
    • Well or unwell
      • Signs suggestive of an unwell child: lethargic, poor interaction, inconsolability, tachycardia, tachypnoea, cyanosis, poor peripheral perfusion
    • Localising signs: Ear, nose and throat examination, neck stiffness, work of breathing, abdominal signs, skin rash, joint swelling

    Investigations:

    Age Description Management
    <1 month corrected age
    (or < 3.5 kg in an older child)
    Rectal temperature > 38oC
    • Discuss with registrar/consultant
    • Full sepsis work-up: FBE/film, blood culture, urine culture (SPA), LP ±  CXR
    • Admit for empirical antibiotics
    1-3 months corrected age Rectal temperature > 38oC
    • Discuss with registrar/consultant
    • Full sepsis workup: FBE/film, blood culture, urine culture (SPA) ± CXR (only if respiratory symptoms or signs) ± LP
    • Discharge home with review within 12 hours if the child is:
      • Previously healthy
      • Looks well
      • WCC 5,000 - 15,000
      • Urine microscopy clear
      • CXR (if taken) clear
      • CSF (if taken) negative
    • If the child is unwell or above criteria are not all satisfied, admit to hospital for observation +/- empiric i.v. antibiotics

     

     Age  Description  Management
     > 3 months  Temperature >38oC and clear focus of infection child looks well
    • Treat as clinically indicated
    child looks unwell
    • Discuss with registrar/consultant
    • Investigate as appropriate for clinical focus
    • Admit for treatment
     > 3 months Temperature >38oC and no clear focus of infection child looks well
    • If < 12 months boys or <2 yrs girls -urine, can do  SPA up to 12 months of age
    • If > 12 months - Consider Urine m,c,s
    • Discharge home on symptomatic treatment
    • Arrange medical review within 24 hr, or sooner if deteriorates
    child looks miserable but is still relatively alert, interactive and responsive
    • If < 12 months boys or <2 yrs girls -urine, can do  SPA up to 12 months of age
    • If > 12 months - Consider Urine m,c,s
    • Discuss with registrar or consultant prior to any investigations
    child looks unwell
    • Full sepsis workup: FBE, blood culture, urine culture ± CXR (if respiratory symptoms or signs) ± LP
    • Admit to hospital for observation +/- i.v. antibiotics
    • LP should not be performed in a child with impaired conscious state, focal neurological signs or who is haemodynamically unstable (see  Lumbar puncture guideline). In this circumstance, treatment for meningitis/encephalitis can be commenced and an LP can be performed when the patient is stable and there are no other contraindications present. 
    • Bag urine specimens should never be sent for culture. If the bag specimen is positive for nitrites &/or leukocytes on reagent strip testing, then an SPA or catheter urine should be performed and the sample sent for culture (see  UTI Guideline). Note children with negative urine strip testing can still have UTI, so if UTI is suspected take SPA urine sample regardless of strip test result

    Management:

    Any febrile child who appears seriously unwell should be investigated and admitted, irrespective of the degree of fever

    • For recommendations for empirical antibiotics refer to  Antibiotic guideline
    • Consider antiviral therapy in children who are encephalopathic, have underlying chronic disease or other risk factors (eg. immunosuppressed) after discussion with senior staff.

    When to admit/consult local paediatric team, or who/when to phone consult at RCH

    • Unwell child
    • Septic shock
    • High-risk patients - immunosuppressed, chronic lung disease, congenital heart disease
    • Advice needed regarding empirical treatment

    When to consider transfer to tertiary centre:

    • Haemodynamic or respiratory instability
    • Encephalopathy
    • High-risk patients - immunosuppressed, chronic lung disease, congenital heart disease
    • Child requiring care above the level of comfort of the local hospital

    For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Discharge requirements

    • Infants less than 1 month of age with fever should be admitted.
    • Infants 1 to 3 months of age:
      • The child is well
      • All investigations are normal
      • The child has been reviewed by a senior registrar/consultant
      • Follow up in 12 hours has been arranged
    • Children older than 3 months:
      • The child is well
      • Follow up has been arranged
     Always advise the parents to return for review if the child is deteriorating

     Information Specific to RCH

    Children with fever are usually admitted under the General Medical Team.

    Parent Information Sheet  (Print version - PDF)

    Additional Notes:

    Positive blood culture

    Contact the family immediately and arrange clinical review:

    a. Strep pneumoniae

    •  - Child well and afebrile:
      1. If the child is on antibiotic therapy, a 7 day course of antibiotics should be completed.
      2. If the child has not received antibiotics, they do not need to be investigated or treated as they have cleared the infection themselves.
      3. Review if clinical deterioration occurs.
    • - Child unwell or febrile:
      • Sepsis workup and admission for i.v. antibiotics

    b. Any other organism (regardless of clinical condition)

    • Discuss with ED Consultant (or General Paediatric Consultant on call if patient is admitted) if isolate is thought to be a contaminant.
    • Sepsis workup and admission for i.v. antibiotics.

    Last update October 2011