Febrile child


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    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
    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 convulsions.

    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