Fever assessment

• CNS, URTI, LRTI, GI, UTI, skin

• Sepsis, observations (cap refill), urine

• Children with ‘red’ features, but who are not considered to have an immediately life-threatening illness should be urgently seen by a healthcare professional in a face-to-face setting within 2 hours if the infant or child was initially assessed by telephone, to help guide whether urgent hospital admission is needed. ‘Red’ features include temperature ≥38 °C in children aged 0–3M, and temperature ≥39 °C in children aged 3–6M

Which is the SINGLE MOST appropriate method for measuring the temperature of children aged four weeks to five years? 

1. Forehead thermometer

2. Infrared tympanic thermometer

3. Mercury thermometer in the axilla

4. Oral electronic thermometer

5. Rectal thermometer

In infants > 4W, body temperature should be checked with an electronic thermometer in the axilla. 

In older children aged 4W to 5Y, body temperature can be checked by either an electronic or a chemical dot thermometer in the axilla or an infra-red tympanic thermometer.

Forehead chemical thermometers are discouraged as they are unreliable.

Question

A mother attends with her one-year-old son. For the past five days he has had a fever with some nasal congestion. He is feeding reasonably well and his nappies are wet with normal bowel motions.

On examination, he is content and smiling with good social interaction. There is normal colour of his skin, lips and tongue. He is well hydrated with moist mucous membranes and good skin turgor.

His temperature is 37.4°C, heart rate is 120 beats/min, respiratory rate is 30 breaths/min with oxygen saturations > 95%. Capillary refill time is two seconds. There are no rashes, meningism or photophobia. Examination of nose, throat, ears, chest and abdomen are normal. Urinalysis is negative.

Using the traffic light system for identifying the likelihood of serious illness, which of the following observations denotes an amber-intermediate risk? 

1. Fever for five days

2. Capillary refill time of two seconds

3. Respiratory rate of 30 breaths/min

4. Heart rate of 120 beats/min

5. Oxygen saturations of > 95%

Children with a feverish illness should be assessed for the presence or absence of symptoms and signs. A traffic light system utilises these symptoms and signs to predict the risk of serious illness.

Specific parameters that are important to measure as part of the routine assessment of a child with fever are Temperature, Heart Rate (HR), Respiratory Rate (RR), Pulse Oximetry, % Oxygen Saturation and Capillary Return Time (CRT).

A full history should be taken and a comprehensive 'top to toe' examination performed.

General examination should consider Colour (skin, lips and tongue), Activity (responsiveness from alert and bright to inactive, unresponsive and weak), Respiration (degrees of breathlessness, nasal flaring, grunts, tachypnoea, crackles), Hydration (well hydrated, normal skin, eyes and mucous membranes to dry skin, dry mucous membranes, poor feeding, reduced urine output and reduced skin turgor). Other signs and symptoms are outlined in the traffic light system.

Each observation/measurement should not be interpreted in isolation. It is important to gain a complete picture by considering all of the information collected.

If any amber features are present and no diagnosis has been reached, referral should be considered or parents/carers should be provided with safety net advice e.g. written information on warning symptoms, specific follow up and how to access further health care.

Oral antibiotics are not recommended for children with fever without an apparent source.

With regard to remote assessment, children with “red” features, who are not considered to have immediately life threatening illness should be urgently assessed by a health care professional in a face-to-face setting within two hours.

Resource:

• Fever in Under 5s: assessment and initial management. NG143. 2019 (updated 2021).

Differential diagnosis

A 4-year-old girl has had a fever for 6 days. She has bilateral conjunctival injection, dry red lips, a polymorphous rash, and cervical lymphadenopathy. Which is the SINGLE MOST likely diagnosis?

1. Erythema toxicum

2. Kawasaki's disease

3. Measles

4. Meningococcal septicaemia

5. Scarlet fever

Erythema toxicum is a common self-limiting rash of neonates. Children with measles have a maculo-papular rash, but red lips would be atypical. Scarlet fever causes an erythematous rash, but no eye signs. Kawasaki disease is an idiopathic self-limiting systemic vasculitis that most often affects children aged 6 months to 5 years. It is the leading cause of acquired heart disease in children in the developed world. 

In order to reach a diagnosis of Kawasaki disease, there must be a history of fever of at least 5 days' duration and at least 4 of the following 5 clinical features: 

1. Inflammation and irritation of the lips, mouth and/or tongue (eg, cracked lips, strawberry tongue, inflamed mucosa of mouth or pharynx)

2. Erythema, oedema and/or desquamation of the extremities

3. Bilateral dry conjunctivitis

4. Widespread non-vesicular rash

5. Cervical lymphadenopathy > 1.5 cm in size

Management

You examine a 5-year-old child who has had a cough and runny nose for 48 hours. He has a temperature of 38°C. There are no significant focal signs. He is very active around your room, showing no signs of being unwell or distressed. With regard to his temperature, apart from general advice, which one of the following is the best intervention?

1. No treatment

2. Tepid sponging

3. Paracetamol

4. Paracetamol with ibuprofen

5. Ibuprofen

Tepid sponging is not recommended for the treatment of fever. Antipyretics should not be used for the sole aim of preventing febrile seizures but can be used in a child with fever who is distressed. Paracetamol and ibuprofen should not be used simultaneously and only to consider alternating these agents if the distress persists or recurs before the next dose is due. 

Resources

• Fever in Under 5s: assessment and initial management (NG 143). 2019.

• Feverish children - risk assessment (CKS)

• Feverish children - management (CKS)