Primary care assessment and management of feverish child less than 5 years old

• recognise that children younger than 3 months with a temperature of 38°C or higher are in a high-risk group for serious illness
• recognise that children aged 3-6 months with a temperature of 39°C or higher are in at least an intermediate-risk group for serious illness
  
  
• do not use duration of fever to predict the likelihood of serious illness. However, children with a fever lasting 5 days or longer should be assessed for Kawasaki disease
  
  
• think "Could this be sepsis?" and refer to the NICE guideline on sepsis: recognition, diagnosis and early management if a child presents with fever and symptoms or signs that indicate possible sepsis
  
  
  • sepsis is a condition of life-threatening organ dysfunction due to a dysregulated host response to infection
• with respect to assessment of the feverish child younger than 5 years old:
  • healthcare professionals should identify any immediately life-threatening features, including compromise of the airway, breathing or circulation, and decreased level of consciousness
  • children with feverish illness should be assessed for the presence or absence of symptoms and signs that can be used to predict the risk of serious illness
  • assess children with feverish illness for the presence or absence of symptoms and signs that can be used to predict the risk of serious illness using the traffic light system (see linked item)
  • when assessing children with learning disabilities, take the individual child's learning disability into account when interpreting the traffic light table
    
    
  • children with the following symptoms or signs should be recognised as being in a high-risk group for serious illness:
    • pale/mottled/ashen/blue skin, lips or tongue
    • no response to social cues
    • appearing ill to a healthcare professional
    • does not wake or if roused
    • does not stay awake
    • weak, high-pitched or continuous cry
    • grunting
    • respiratory rate greater than 60 breaths per minute
    • moderate or severe chest indrawing
    • reduced skin turgor
    • bulging fontanelle
      
      
  • children with any of the following symptoms should be recognised as being in at least an intermediate-risk group for serious illness:
    • pallor of skin, lips or tongue reported by parent or carer
    • not responding normally to social cues
    • no smile
    • wakes only with prolonged stimulation
    • decreased activity
    • nasal flaring
    • dry mucous membranes
    • poor feeding in infants
    • reduced urine output
    • rigors
      
      
  • children who have all of the following features, and none of the high or intermediate risk features, should be recognised as being in a low-risk group for serious illness:
    • normal colour of skin, lips and tongue
    • responds normally to social cues
    • content/smiles
    • stays awake or awakens quickly
    • strong normal cry or not crying
    • normal skin and eyes
      
      
  • healthcare professionals should measure and record temperature, heart rate, respiratory rate and capillary refill time as part of the routine assessment of a child with fever
    
    
  • healthcare professionals examining children with fever should be aware that a raised heart rate can be a sign of serious illness, particularly septic shock
    
    
  • recognise that a capillary refill time of 3 seconds or longer is an intermediaterisk group marker for serious illness ('amber' sign).
    
    
  • healthcare professionals should measure the blood pressure of children with fever if the heart rate or capillary refill time is abnormal and the facilities to measure blood pressure are available
    
    
  • in children older than 6 months do not use height of body temperature alone to identify those with serious illness
    
    
  • recognise that children younger than 3 months with a temperature of 38°C or higher are in a high-risk group for serious illness
    
    
  • recognise that children aged 3-6 months with a temperature of 39°C or higher are in at least an intermediate-risk group for serious illness
    
    
  • do not use duration of fever to predict the likelihood of serious illness. However, children with a fever lasting more than 5 days should be assessed for Kawasaki disease
    
    
  • recognise that children with tachycardia are in at least an intermediate-risk group for serious illness. Use the Advanced Paediatric Life Support (APLS) criteria below to define tachycardia

• children with fever should be assessed for signs of dehydration. Healthcare professionals should look for:
  • prolonged capillary refill time
  • abnormal skin turgor
  • abnormal respiratory pattern
  • weak pulse
  • cool extremities

Management in by the non-paediatric specialist:

• if symptoms or combination of symptoms and signs suggest an immediately life-threatening illness then should be referred immediately for emergency medical care by the most appropriate means of transport (usually 999 ambulance)
• children with any high-risk features ('red') but who are not considered to have an immediately life-threatening illness should be referred urgently to the care of a paediatric specialist
• if any intermediate ('amber') features are present and no diagnosis has been reached, healthcare professionals should provide parents or carers with a 'safety net' or refer to specialist paediatric care for further assessment. The safety net should be one or more of the following:
  • providing the parent or carer with verbal and/or written information on warning symptoms and how further healthcare can be accessed
  • arranging further follow-up at a specified time and place
  • liaising with other healthcare professionals, including out-of-hours providers, to ensure direct access for the child if further assessment is required
• children with low-risk features ('green') and none of the intermediate-risk ('amber) or high-risk ('red') features can be managed at home with appropriate advice for parents and carers, including advice on when to seek further attention from the healthcare services

Notes:

• children with symptoms and signs suggesting pneumonia who are not admitted to hospital should not routinely have a chest X-ray
• urine should be tested on children with fever
• oral antibiotics should not be prescribed to children with fever without apparent source.
• children with suspected meningococcal disease should be given parenteral antibiotics at the earliest opportunity (either benzylpenicillin or a third-generation cephalosporin)

Reference:

• NICE (November 2021). Feverish illness in children Assessment and initial management in children younger than 5 years