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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

    Fever and suspected or confirmed neutropenia 
    Fever in the recently returned traveller

    Kawasaki disease

    Petechiae and Purpura
    Sepsis – assessment and management
    Local antimicrobial guidelines

    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. In Febrile infants >28 days of corrected age and <3 months, have a low threshold for investigation and treatment based on clinical appearance and presence (or absence) of a clinically obvious focus
    3. In infants <3 months of age, hypothermia or temperature instability can be signs of serious bacterial infection (or other serious illness)
    4. The severity of illness cannot be predicted by the degree of fever, its rapidity of onset, its response to antipyretics or the presence of febrile seizures; the appearance of the child is the most useful indicator 

    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 causes of fever in children are viral infections, however serious bacterial infections (SBIs) need to be considered
    • The most common SBIs found in children without a focus are urinary tract infections 
    • Other SBIs to consider include: pneumonia, meningitis, bone and joint infections, skin and soft tissue infections, mastoiditis, bacteraemia, sepsis
      • Since the introduction of the pneumococcal vaccine, the rate of occult bacteraemia has fallen to <1% in healthy, immunised children
    • Children with fever for ≥5 days should be assessed for  Kawasaki disease or  PIMS-TS if there is a history of COVID-19 infection
    • Other uncommon causes of prolonged fever in children include inflammatory, immune-mediated and neoplastic conditions; specialist input may be required

    Assessment

    History

    • Localising symptoms eg cough, headache, photophobia, diarrhoea, vomiting, abdominal pain, musculoskeletal pain, rash
    • 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: prematurity, immunosuppression/oncological conditions (see  Fever and suspected or confirmed neutropenia), central line in situ, chronic lung disease, congenital heart disease, previous invasive bacterial infections, children of Aboriginal, Torres Strait Islander, Pacific Islander or Maori origin, multiple health service presentations

    Notes

    • Teething does not cause fever
    • Post vaccination fever is common, with a typical onset within 24 hours of immunisation and duration up to 2-3 days; however, in an unwell child, fever should not be attributed to vaccination alone

    Examination

    Certain aspects of the child's behaviour and appearance provide the best indication of whether they are at high risk of SBI

    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 capillary refill time ≥3 seconds
    Reduced skin turgor
    Reduced urine output

    Neurological

    Bulging fontanelle

    Excessive irritability
    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

    Adapted from: Feverish illness in children NICE guideline 2019

    The child should be examined for a clinical focus of infection 

    • Remove clothing as required to complete a full examination, looking for subtle signs  

    Management

    • Any febrile child who appears seriously unwell should be managed as suspected sepsis (see Sepsis), irrespective of the degree of fever
    • Do not accept apparent otitis media or upper respiratory symptoms as the source of infection in young infants or unwell children. These children still require assessment for possible SBI
    • If the child is stable, it is preferable to complete investigations looking for an infective focus before commencing antibiotics 
    • In children from high risk groups, have a lower threshold for investigations
    • UTI is the most common SBI, if there is no clinically obvious focus for fever, urine collection and testing should be performed
    • When blood cultures are indicated, ensure adequate volume collected (see Additional notes below)
    • Antimicrobial recommendations may vary according to local antimicrobial susceptibility patterns; please refer to  local guidelines

    Infants ≤ 28 days corrected age 

    • Assess promptly for signs of sepsis and discuss with a senior doctor. See Recognition of the seriously unwell neonate and young infant 
    • FBE, CRP, blood culture, urine (by SPA; see section on Urine collection below for other methods), LP ± CXR 
    • Prompt treatment with empiric antibiotics 
      • If the infant appears unwell, or there is likely to be a delay in completing all of the required investigations, proceed with administration of antibiotics


    Infants 29 days to 3 months corrected age


    Children >3 months corrected age

    Consider consultation with local paediatric team when

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

    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 of 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   

    Fever in children      


    Additional resources

    Fever in under 5s: assessment and initial management. NICE guideline 2019 


    Additional notes

    Temperature measurements

    • Axillary temperature: recommended for infants <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 children >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: forehead or infrared thermometers are unreliable
    • Rectal temperature: in neonates, screen first with axillary temperature, then consider performing a rectal temperature if a fever is still suspected

    Lumbar puncture

    • When indicated, LP should be performed without delay and, ideally, before the administration of antibiotics 
    • Contraindications to LP include impaired conscious state, focal neurological signs, impaired coagulation or haemodynamic instability  
    • In this circumstance, treatment for meningitis/encephalitis should be commenced and an LP performed when the child is stable and there are no contraindications 
    • See Lumbar puncture 

    Urine collection

    • Bag urine specimens should never be sent for culture due to high false positive rates - contamination rate 50% 
    • Suprapubic aspirate (see  SPA): gold standard - contamination rate 1%
    • In/out catheter: useful if there is little urine in the bladder, such as after failed clean catch or SPA (discard first few drops of urine if possible to reduce contamination) - contamination rate 10% 
    • Midstream urine (MSU): preferred method for toilet-trained children who can void on request - contamination rate 25% 
    • Clean catch: appropriate for pre-continent children who cannot void on request, but are not seriously unwell (yield may be improved by gently rubbing child’s suprapubic area with gauze soaked in cold fluid, see  urine tests) - contamination rate 25% 

    The perineal/genital area should be cleaned with saline-soaked gauze for 10 seconds before collecting midstream or clean catch urine 

    See Urinary tract infection 


    Blood culture

    • Blood cultures should be taken using an aseptic technique and sterile gloves 
    • Accuracy of blood culture results rely on correct blood volume to improve detection of bacteraemia or fungaemia  
    • Inoculate aerobic bottle preferentially, ie if inadequate volume for both bottles 

    Volume and type of blood culture:


    Weight

    Paediatric aerobic bottle (for small volumes)

    Adult aerobic bottle

    Adult anaerobic bottle

    Min vol: 0.5 mL
    Max vol: 4 mL

    Min vol: 5 mL
    Max vol: 10 mL

    <1.5 kg

    1 mL

     

    N/A (unless specific clinical indication)

    1.5-5 kg

    1.5 mL

     

    5-10 kg

    3 mL

     

    5 mL

    11-15 kg

    4 mL

     

    5 mL

    16-20 kg

    Use green bottle whenever >4 mL collected

    6 mL

    If anaerobic BC not indicated, put 10 mL in aerobic bottle

    6 mL

    21-25 kg

    8 mL

    8 mL

    >25 kg

    10 mL

    10 mL

    Last update September 2022

  • Reference List

    1. Alejandre C, Guitart C, Balaguer M, Torrus I, Bobillo-Perez S, Cambra FJ, et al. Use of procalcitonin and C-reactive protein in the diagnosis of bacterial infection in infants with severe bronchiolitis. European Journal of Pediatrics. 2021;180(3):833-42.
    2. Biondi EA, Lee B, Ralston SL, Winikor JM, Lynn JF, Dixon A, et al. Prevalence of Bacteremia and Bacterial Meningitis in Febrile Neonates and Infants in the Second Month of Life: A Systematic Review and Meta-analysis. JAMA Network Open. 2019;2(3):e190874.
    3. Bonadio W, Huang F, Nateson S, Okpalaji C, Kodsi A, Sokolovsky S, et al. Meta-analysis to Determine Risk for Serious Bacterial Infection in Febrile Outpatient Neonates With RSV Infection. Pediatric Emergency Care. 2016;32(5):286-9.
    4. Craig JC, Williams GJ, Jones M, Codarini M, Macaskill P, Hayen A, et al. The accuracy of clinical symptoms and signs for the diagnosis of serious bacterial infection in young febrile children: prospective cohort study of 15 781 febrile illnesses. BMJ. 2010;340:c1594.
    5. Dodd SR, Lancaster GA, Craig JV, Smyth RL, Williamson PR. In a systematic review, infrared ear thermometry for fever diagnosis in children finds poor sensitivity. Journal of Clinical Epidemiology. 2006;59(4):354-7.
    6. Elkhunovich MA, Wang VJ, Pham P, Arpilleda JC, Clingenpeel JM, Mansour K, et al. Assessing the Utility of Urine Testing in Febrile Infants 2 to 12 Months of Age With Bronchiolitis. Pediatric Emergency Care. 2019;03:03.
    7. Fever in under 5s: assessment and initial management. NICE guideline 2019. https://www.nice.org.uk/guidance/ng143 (viewed 5th September 2022).
    8. Gomez B, Mintegi S, Bressan S, Da Dalt L, Gervaix A, Lacroix L, et al. Validation of the "Step-by-Step" Approach in the Management of Young Febrile Infants. 2016.
    9. Hsiao AL, Baker MD. Fever in the new millennium: a review of recent studies of markers of serious bacterial infection in febrile children. Current Opinion in Pediatrics. 2005;17(1):56-61.
    10. Irwin AD, Wickenden J, Le Doare K, Ladhani S, Sharland M. Supporting decisions to increase the safe discharge of children with febrile illness from the emergency department: a systematic review and meta-analysis. Archives of Disease in Childhood. 2016;101(3):259-66.