See also

Febrile Neutropenia
Fever and Petechiae
Fever in the recently returned traveller
Sepsis – assessment and management
Antibiotics

Key points

1. Febrile neonates ≤28 days of corrected age require investigations (FBE; CRP; blood, urine and CSF cultures; ± CXR) and empiric iv antibiotic therapy
2. Febrile infants >28 days of corrected age and <3 months should be investigated based on clinical appearance and presence of a localised infective focus. There should always be a low threshold for relevant investigations and treatment, and complications of a clinical focus should be considered.
3. Remember that in babies under 3 months of age, hypothermia or temperature instability can be signs of serious bacterial infection (or other serious illness).
4. The following are not good predictors of serious illness: degree of the fever, its rapidity of onset, its response to antipyretics, simple febrile seizures.

Background

Definition of fever: body temperature >38.0º Celsius

Where possible, use the same body site and the same type of thermometer when measuring temperatures ( see Additional notes) .

The most common serious bacterial infections (SBIs) found in children without a focus are urinary tract infections. Since the introduction of the pneumococcal vaccine, the rate of occult bacteraemia has fallen to <1% in healthy, immunised infants.

Other SBIs to consider include: pneumonia, meningitis, bone and joint infections, skin and soft tissue infections, mastoiditis, bacteraemia, sepsis.

Assessment

History

• Travel
• Sick contacts
• Immunisation: children <6 months age or with incomplete immunisation
• Medication – prior treatment with antibiotics may mask signs of a bacterial infection
• High risk groups: prematurity, immunosuppression, central line, chronic lung disease, congenital heart disease, previous invasive bacterial infections, ATSI population.
  

Teething does not cause fever

Examination

• General aspects of the child's behaviour and appearance provide the best indication of whether SBI is likely.

Features suggestive of an unwell child:

*NB Pallor, poor feeding or decreased activity on their own may not suggest a seriously unwell child.
Adapted from: Feverish illness in children NICE guideline 2017

Investigations and Management

• Any febrile child who appears seriously unwell should be investigated and admitted, irrespective of the degree of fever.
• If the patient is stable, it is preferable to complete investigations looking for a focus before commencing antibiotics. Otherwise, assess for signs of shock and manage as per Sepsis.
• Do not accept apparent otitis media or upper respiratory symptoms as the source of infection in young infants or unwell children. These patients still require assessment for possible SBI.
• In children from high risk groups, have a lower threshold for investigations. 

Infants ≤ 28 days corrected age

• Should be assessed promptly and discussed with a senior doctor
• FBE, CRP, blood culture, urine (SPA), LP ± CXR
• admit for empiric antibiotics

Infants 29 days to 3 months corrected age

* Pallor, poor feeding or decreased activity on their own may not suggest a seriously unwell child.

Children >3 months corrected age

* Pallor, poor feeding or decreased activity on their own may not suggest a seriously unwell child.

Consider consultation with local paediatric team when:

• Unwell child
• Septic shock
• Infants <28 days corrected age with fever (should be admitted)
• Barriers to follow-up within 24 hours due to social or external factors (consider admission)
• High-risk patients
• Advice needed regarding empiric treatment

Consider transfer to tertiary centre when:

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.

Consider discharge when:

• Infants 29 days to 3 months corrected age: well, investigations normal, discussed with senior doctor, follow-up within 12-24 hours has been arranged.
• Children >3 months corrected age: well, follow up has been arranged.
• Always advise parents to return for review if the child is deteriorating.

Parent Information Sheet  

Fever in children      

Additional notes:

Temperature measurements

• Axillary temperature: recommended for patients <3 months of age
• For a more accurate reading, the thermometer should be placed over the axillary artery for 3 minutes.
• Tympanic temperature: recommended for patients >3 months of age. For an accurate measurement, the pinna must be retracted to straighten the external auditory meatus and the instrument should be directed at the tympanic membrane.
• Skin temperature: unreliable
• Rectal temperature: in neonates, screen first with axillary temperature, then consider performing a rectal temperature if a fever is still suspected.

Lumbar puncture

• LP should not be performed in a child with impaired conscious state, focal neurological signs impaired coagulation or haemodynamic instability (see Lumbar puncture). 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. 

Urine collection

• Bag urine specimens should never be sent for culture. If a bag specimen is positive for nitrites &/or leukocytes on reagent strip testing, a proper urine specimen should be collected and the sample sent for culture prior to commencing treatment. (see  UTI ).

Positive blood culture

Discuss with a senior doctor then contact the family immediately and arrange clinical review.

Last update August 2018