Fever in paediatrics Dr Ehsan Ahmed (Consultant Paediatrician Walsall Manor Hospital) Dr Sasan Iraji GPVTS1

Fever Indicates infection in child<5yr in most cases Parental perceptions of fever are accurate

Fever definition A fever is a high temperature. As a general rule, in children, a temperature of over 37.5°C (99.5°F) is a fever

Thermometers and the detection of fever Do not routinely use the oral and rectal routes to measure the body temperature of children aged 0–5 years. In infants <4 weeks use electronic thermometer in the axilla. In children 4wk- 5yrs use one of the following: electronic thermometer in the axilla chemical dot thermometer in the axilla infra-red tympanic thermometer - Forehead chemical thermometers are unreliable - Reported parental perception of a fever should be considered valid and taken seriously by healthcare professionals

NICE Guideline overview

Remote assessment identify symptoms and signs of serious illness using the traffic light system and specific diseases

Traffic light system for assessment

Traffic light system Red : Face-to-face assessment by a healthcare professional within 2 hours. Amber : Face-to-face assessment by a healthcare professional- The urgency of this assessment should be determined by the clinical judgement of the healthcare professional carrying out the remote assessment Green : Suitable for home care

Identify life-threatening features Airway, breathing or circulation compromise and decreased level of consciousness (A,B,C,D approach)

Face to face assessment; Use the traffic light system to assess risk of serious illness Routinely check T, HR, RR and capillary refill time, BP Children <3 months with T 38°C or higher → high-risk group Children 3-6 months with T 39°C or higher, CRT>3 sec and Children with tachycardia → At least Amber group Fever >5 days assess for Kawasaki dx Do not forget travel history

(APLS) criteria for tachycardia Can be an initial and subtle sign of sepsis Age Heart rate (bpm) <12 months >160 12–24 months >150 2–5 years >140

Signs of dehydration Prolonged capillary refill time Abnormal skin turgor Abnormal respiratory pattern Weak pulse Cool extremities Oliguria

Other signs and symptoms in high risk group (Red light) → Urgent referral 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. Petechial rash

Other signs and symptoms in intermediate risk group (amber light) → face-to-face assessment 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

Symptoms and signs of specific illnesses after initial traffic light- face to face assessment

Meningoccocal disease and bacterial meningitis Consider meningococcal disease in any child with fever and a non-blanching rash (petechiae or purpura), particularly if any of the following features are present: - an ill-looking child - lesions larger than 2 mm in diameter (purpura) - a capillary refill time of 3 seconds or longer - neck stiffness.

Meningoccocal disease and bacterial meningitis Consider bacterial meningitis in a child with fever and any of the following features: - neck stiffness - bulging fontanelle - decreased level of consciousness - convulsive status epilepticus.

Herpes simplex encephalitis Consider in a child with fever and any of the following: focal neurological signs focal seizures decreased level of consciousness.

Pneumonia Fever and any of the following signs tachypnoea crackles nasal flaring Recession cyanosis oxygen saturation ≤95% in room air

Urinary tract infection - Consider in any child <3 months with fever - Consider UTI in >3 months with fever and any of the following vomiting poor feeding lethargy irritability abdominal pain or tenderness urinary frequency or dysuria

Septic arthritis or osteomyelitis - Fever and any of the following signs: swelling of a limb or joint not using an extremity Limping non-weight bearing

Kawasaki disease Fever for 5 days and 4 of the following 5 features WARM CREAM (non-purulent Conjunctivitis, Rash, palmar Erythema/swelling, cervical Adenopathy, dry and red Mucous membranes, strawberry tongue )

Bacterial meningitis and meningococcal septicaemia overview

Pre- hospital management of suspected meningitis

Management a child with fever by non-paediatric practitioners Three stages assessment: 1- Identify life-threatening features (A,B,C,D) 2- Traffic light system for assessment 3- Attempt to identify source of infection/feature Red features: urgent referral to paediatric specialist

Management a child with fever by non-paediatric practitioners Amber features: If any 'amber' features but no diagnosis a) safety nets to parents (verbal and/or written information on warning symptoms, arranging further follow-up or access to OOH providers) ------OR------ b) referral to paediatric team Green features: home care with appropriate advice

Antipyretic interventions Antipyretic agents do not prevent febrile convulsions and should not be used specifically for this purpose Tepid sponging is not recommended Children with fever should not be underdressed or over-wrapped. Consider using either paracetamol or ibuprofen in children with fever who appear distressed.

Antipyretic interventions When using paracetamol or ibuprofen in children with fever: continue only as long as the child appears distressed do not give both agents simultaneously only consider alternating these agents if the distress persists or recurs before the next dose is due

Advice for home care To encourage their child to drink more fluids How to detect signs of dehydration How to identify a non-blanching rash To check their child during the night To keep their child away from nursery or school

When to seek further help Any fits Non-blanching rash Child is less well than when they previously sought advice Parents are more worried than when they previously sought advice Fever > 5 days the parent is distressed, or concerned that they are unable to look after their child.

Take home messages Three stages assessment in a child with fever: 1- Identify life-threatening features (A,B,C,D) 2- Traffic light system for assessment. Prompt action as per clinical assessment. 3- Attempt to identify source of infection/feature and treat or act as necessary.

Take home messages Children <3 months with fever → high-risk group Children 3-6 months with T 39°C or higher, CRT>3 sec and Children with tachycardia → At least Amber group Do not give paracetamol and ibuprofen simultaneously Parental education and safety nets

THANKS FOR LISTENING ANY QUESTIONS?

References http://pathways.nice.org.uk/pathways/feverish-illness-in-children Paediatric Guidelines 2013-2014, Bedside Clinical Guideline Partnership http://pathways.nice.org.uk/pathways/bacterial-meningitis-and-meningococcal-septicaemia http://www.uptodate.com/contents/fever-in-children-beyond-the-basics http://www.nice.org.uk/guidance/cg160/chapter/key-priorities-for-implementation