HNY Policy and Pathway Repository - York

Feverish illness is diagnosed in all children who present with a temperature over 38°C as measured by the following;

• In those <4 weeks – electronic thermometer placed in axilla
• In those >4 weeks – chemical dot in axilla, electronic thermometer in axilla or infra-red tympanic thermometer.

For emergency hospital admission

• Children with fever who appear shocked, unrousable or show signs of meningococcal disease
• Children under 3 months with a temperature ≥ 38°C
   

Low Threshold for Admission

• Children aged 3-6 months with a temperature ≥ 39°C

General Points

• Very common in young children, with between 20-40% of parents reporting such an illness each year
• Fever usually indicates underlying infection
• It is a cause of significant worry for parents and carers
• It is the second most common reason for a child being admitted to hospital
• Infections remain the leading cause of death in children under 5 years
• Diagnosing the cause of fever can be a significant challenge and even after a detailed assessment the cause may remain elusive, ‘pyrexia of unknown origin’
• Ask parents about the presence features since the onset of fever, because they may have resolved by the time of assessment

Assessment

• Consider observations outside of the consultation room
  It can be helpful to view the waiting room as an extension of the consultation room. If the child is unwell within the consultation then consider keeping them for 30 minutes in the waiting room to see if things settle. Consider arranging a review later that day or within 24-48h. This could be face to face or virtual depending on the clinician’s and parents’ comfort with either.
   
• Listen to parental concerns
  A parent’s report of fever should be considered valid, even if the child has a normal temperature in the consultation room. It is important that parental or carer’s concerns are elicited and addressed
   
• Measure temperature accurately 
  • In those <4 weeks – electronic thermometer placed in axilla
  • In those >4 weeks – chemical dot in axilla, electronic thermometer in axilla or infra-red tympanic thermometer. Wax doesn’t affect the reading.
     
• Examine child thoroughly
  • Leave examinations that are most likely to upset the child to the end.
  • Undress the child fully to ensure no rashes or otherbclinical signs that could point to the cause of fever are not missed.
  • Look carefully for common causes of fever such as tonsillitis, upper and lower respiratory tract infections.
  • Document temperature, heart rate, respiratory rate and capillary refill time
  • Assess for signs of dehydration

• Exclude serious infection

• Consider investigations
  • Children presenting with an unexplained fever (T ³38°C) should have urine testing within 24h
  • Chest x-rays should not be routinely organised for children thought to have pneumonia
     

Management

Non-Pharmacological Methods

• Tepid sponging is not recommended for the treatment of fever
• Children with fever should not be under dressed or over- wrapped

Anti-pyretic Medication

• Anti-pyretic agents do not prevent febrile convulsions and should not be used specifically for this purpose
• Consider using either paracetamol or ibuprofen in children with fever who appear distressed
• Do not use anti-pyretic agents with the sole aim of reducing body temperature in children with fever
• When using paracetamol or ibuprofen in children with fever:
  • Continue only as long as the child appears distressed
  • Consider changing to the other agent if the child’s distress is not alleviated
  • Do not give both agents simultaneously
  • Only consider alternating these agents if the distress persists or recurs before the next dose is due
• When a child has been given anti-pyretics, do not rely on a decrease or lack of decrease in temperature at 1-2 hours to differentiate between serious and non-serious illness
• Advise the parent/carer that paracetamol and ibuprofen are available to purchase OTC

Antibiotic Medication

• Do not prescribe oral antibiotics to children with fever without an apparent source.

When to Arrange Emergency Hospital Admission

• Children with fever who appear shocked, unrousable or show signs of meningococcal disease
• All Children under 3m (because sepsis or meningitis is more likely so a full septic screen is needed).

While awaiting admission to hospital

• Give controlled supplementary oxygen to all children with symptoms of severe illness or impending respiratory failure
• Emergency treatment of sepsis, before urgent transfer to hospital if transfer time >1h:
  • Benzylpenicillin IM
    1y: 300mg
    1-9y: 600mg

If parents or carers think there’s a history of allergy NICE guidance (CG102) on Suspected meningococcal disease (meningitis with non-blanching rash or meningococcal septicaemia) may help. It says in paragraph 1.2.5: “Withhold benzylpenicillin only in children and young people who have a clear history of anaphylaxis after a previous dose; a history of a rash following penicillin is not a contraindication”.

The number of children who have had anaphylaxis to previous dose of benzylpenicillin will only be a very small number. If time permits where the extent of allergy is unclear clinicians should discuss the risk with parents / carers of both administering and not administering potentially lifesaving antibiotics and inform them of the NICE guidance.

When to Consider Hospital Admission

• Children aged over 3m without an apparent source, a period of observation in hospital should be considered as part of an assessment to help differentiate non-serious from serious illness
• In additional to the child’s clinical condition, consider the following factors when deciding to admit a child with fever
  • Social and family circumstances
  • Co-morbidities
  • Parental anxiety and instinct (based on their knowledge of the child)
  • Contacts with other people who have serious infectious diseases
  • Recent travel abroad to tropical/subtropical areas, or areas with high risk of endemic infectious disease
  • When the parent/carer’s concern for their child’s current illness has caused them to seek medical advice repeatedly
  • When the family has experienced a previous serious illness or death due to feverish illness which has increased their anxiety levels
  • When a feverish illness has no obvious cause, but the child remains ill longer than expected for a self-limited illness

Low Risk for Community Management

• Consideration should be given to urine testing. 
• If the child is well enough to be managed in the community they should be given appropriate advice as follows
  • How to manage fever
  • To encourage oral fluids
  • How to detect signs of dehydration – including when they should seek advice
  • How to identify a non-blanching rash
  • To check their child during the night
  • Keep away from school or nursery until fever has improved
• Parents should seek medical attention if
  • The child has a seizure
  • Fever lasts longer than days
  • Child becomes more unwell
  • Parent/carer is distressed or concerned that they are unable to look after their child
  • A non-blanching rash develops

Patient information leaflets/ PDAs

Parent leaflet on Fever

Parent leaflet on Fever and Febrile Convulsion

Fever Pathway for Clinicians

Vocare Leaflet - How to Recognise if your Child is Seriously Ill
 

References

• National Institute for Clinical Excellent [NICE] (2019) Fever in under 5s: assessment and initial management [NG143] [Viewed 12 Nov 2021]
• National Institute for Clinical Excellent [NICE] (Updated 2018) Urinary tract infection in under 16s: diagnosis and management [CG54] [Viewed 12 Nov 2021]
• National Institute for Clinical Excellent [NICE] (2015) Meningitis (bacterial) and meningococcal septicaemia in under 16s: recognition, diagnosis and management (CG102) [Viewed 7 Dec 21]