Fever in children
History/questionnaire:
History from:
Fever?
- Onset? - Fever for ≥ 5 days?
- Measured (how)?
- Highest temperature and when?
- Going down with paracetamol or ibuprofen within 15-30 minutes?
- Exaggerated shivering (rigors)?
Associated symptoms?
- Sneezing?
- Cough?
- Vomiting? -- Repeated vomiting (how many times in the last 24 hours)?
-- When was last vomit? -- Bile stained (green or green-yellow), bloody or black vomit?
- Diarrhoea?
-- Loose or watery stools?
-- Blood in the stools (how much)? - Reduced fluid intake (50-75% of usual intake over last 3-4 feeds)? - Marked reduced fluid intake (< 50% of usual intake over last 2-3 feeds)? - Not tolerating fluids/repeated vomiting?
- Unable to swallow saliva? - No urine output for 8 h?
- No urine output for > 24 h?
- Headache? - Photophobia?
- (Focal) seizure or status epilepticus? - Swelling of a limb or joint? - Non-weight bearing limb or not using an extremity? - Leg pain? - Unexplained body pain, including limb, back or abdominal pain?
- Additional parental/carer support required?
Past medical history?
- Perinatal complications?
- Risk factors for severe disease? -- Prematurity (< 35 weeks)?
-- Age < 6 week (corrected)?
-- Pre-existing lung condition (e.g. asthma, chronic lung disease or bronchiectasis/CF)?
-- Congenital heart disease?
-- Immunocompromised? -- Neuromuscular weakness?
Immunisation history?
Recent foreign travel (which countries)?
Recent contact with people with infectious diseases (eg COVID-19)?
Covid-19 lateral flow test(s) (when, result)?
Regular medication(s)?
Recent fever reducing drug(s)?
- Paracetamol (Calpol) (time of last dose)?
- Ibuprofen (Nurofen) (time of last dose)?
- Other (name, time of last dose)?
Recent antibiotic use (name, duration)?
Known drug allergies (name of drugs)?
Examination:
Colour (of skin, lips and tongue)? - Normal?
- Pallor (reported by parent or carer)?
- Pale, mottled, ashen, blue? - Cyanitic lips and tongue?
- Ill appearance?
- Bulging fontanelle? - Non-blanching rash that does not go away with pressure ('Glass Test') (petechial or purpuric rash) (with lesions larger than 2 mm), rapidly progressive and/or spreading?
Activity & behaviour? - AVPU scale?
- Responds normally to social cues, content or smiles, stays awake or awakens quickly, strong normal cry or not crying?
- Decreased activity?
- Irritable (unable to settle with toys, TV, food or hugs even after fever has come down)?
- Lethargic?
- Reduced response to social cues? - No smile? - Wakes only after prolonged stimulation? - Floppy?
- No response to social cues?
- Appears ill to a healthcare professional?
- Does not wake or only wakes with prolonged stimulation or if roused does not stay awake? - Weak, high pitched or continuous cry?
- Very sleepy?
- Confused?
- Weak, high pitched or continuous cry?
Neurological:
- Altered level of consciousness or recognition (including confusion and delirium)? - Neck stiffness (including more subtle discomfort or reluctance to move the neck)?
- Focal neurological deficits/signs, (focal) seizures or status epilepticus?
- Kernig’s sign?
- Brudzinski’s sign?
Temperature?
- T (°C)? Fever in the 48 h following vaccinations and no other concerning features?
- ≥ 39°C and aged 3-6 months?
- ≥ 38°C and aged < 3 months?
- < 36°C when checked 3 times in a 10-minute period in any age?
Breathing?
- RR?
- < 1 y: 50-59?
- 1-2 y: 40-49 ?
- 3-4 y: 35-39? - 5y: 24-28?
- 6-7: 24-26?
- 8-11 y: 22-24?
- 12+ y: 21-24?
- Any age: > 60?
- < 1 y: > 60?
- 1-2 y: > 50?
- 3-4 y: > 40?
- 5 y: ≥ 29?
- 6-7 y: ≥ 27?
- 8-11: ≥ 25?
- 12+ y: ≥ 25?
- Increased work of breathing? - (Severe) respiratory distress?
- Unable to complete sentences?
- Pauses in breathing (apnoea)?
- Audible stridor only on exertion/distress?
- Audible stridor at rest?
- Grunting every time when breathes out ?
- Nasal flaring?
- Drawing in of the muscles at the neck?
- Drawing in between the ribs?
- Drawing in of the muscles below the ribs (abdominal recession)?
- Crackles on chest auscultation? - SpO2 (%)?
- SpO2 92-94(95)%? - SpO2 < 90-92%? - Cyanosed?
- Sudden onset and parental concern about inhaled foreign body?
Circulation and hydration?
- Dry lips, mouth and tongue? - Reduced skin turgor, sunken eyes, sunken anterior fontanelle (usually closed by 18 months)? - Cold hands or feet?
- BP? - Low age-specific blood pressure? - HR?
- < 1 y: 150 - 159?
- 1-2 y: 140 -149?
- 3-4 y: 130 -139?
- 5 y: 120-129?
- 6-7 y: 110-119?
- 8-11 y: 105-114?
- 12+ y: 91-130 (100-130 in pregnancy)?
- < 1 y: > 160?
- 1-2 y: > 150?
- 3-4 y: > 140? - 5 y: > 130?
- 6-7 y: > 120?
- 8-11 y: > 115?
- 12+ y: > 130?
- Any age: <60?
- CRT 2-3 seconds?
- CRT > 3 seconds?
Other?
- Swelling of a limb or joint?
- Non-weight bearing limb/not using an extremity?
- Abdomen?
-- Abdomen distended?
-- Abdomen soft?
-- Apparent abdominal tenderness?
Management:
Advised to take child to paediatric A&E department immediately
Advised to take child to UTC for face-to-face (F2F) assessment
Safety net advice given: Advised to google + read online info of:
- NHS Health A to Z: High temperature (fever) in children
- Medicines for Children: How to give different types of medicines
Paracetamol or ibuprofen (if no vomiting) if fever/distress, to read package leaflet, particularly regarding dosage instructions
To not underdress or over-wrap child
Regular fluids and high fluid intake if signs of dehydration
Saline nasal drops if dried snot (mucus)
To check the child regularly, including during the night (the frequency depending on the clinical situation)
To keep the child away from nursery until they are recovered and to notify nursery about the illness
To visit www.gov.uk to read about and follow the current coronavirus advice, particularly regarding self-isolation and testing
Covid-19 test if not already done
To call back or go to local paediatric A&E if new or worsening symptoms (eg laboured/rapid breathing, not drinking at least 50% of usual intake, not passing urine within 12 h, crying for a long time despite distraction, pale or mottled (blotchy) skin that feels unusually cold, confused, sleepy all the time, difficult to be woken up)
To contact own GP for follow-up if no improvement or ongoing symptoms/concerns
Resource(s):
Healthier Together for Professional
Healthies Together: All Paediatric Pathways
Healthier Together: Fever Pathway
Healthier Together: Bronchiolitis Pathway Healthier Together: Cough/breathlessness in child < 1 year of age Healthier Together: Cough/breathlessness pathway for children ≥ 1 year of age
UK Health Security Agency (UKHSA): Group A Streptococcus
Information for parents/carers:
Medicines for Children: How to give different types of medicines. As per 13 July 2024
NHS Health A to Z: High temperature (fever) in children. Last reviewed: 03 January 2024
Patient UK: Fever in children. Latest revision: 25 September 2023