See also
Febrile Neutropenia
Fever and Petechiae
Fever in the recently returned traveller
Sepsis – assessment and management
Antibiotics
NB Cases of PIMS-TS - a novel post-infectious systemic hyperinflammatory syndrome - have been reported in children in Victoria. See alert
Key points
- Febrile neonates ≤28 days of corrected age require investigations (FBE; CRP; blood, urine and CSF cultures; ± CXR) and empiric iv antibiotic therapy
- 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.
- Remember that in babies under 3 months of age, hypothermia or temperature instability can be signs of serious bacterial infection (or other serious illness).
- 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:
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 |
*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