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Febrile child


  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also

    Febrile Neutropenia
    Fever and Petechiae
    Fever in the recently returned traveller
    Sepsis – assessment and management
    Local antimicrobial guidelines

    NB Cases of PIMS-TS - a novel post-infectious systemic hyperinflammatory syndrome - have been reported in children in Victoria. See alert

    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 below)

    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