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

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

3. 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

4. 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

5. NICE Guideline overview

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

7. Traffic light system for assessment

8. 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

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

10. 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

11. (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

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

13. 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

14. 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

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

16. 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.

17. 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.

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

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

20. 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

21. 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

22. 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 )

23. Bacterial meningitis and meningococcal septicaemia overview

24. Pre- hospital management of suspected meningitis

25. 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

26. 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

27. 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.

28. 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

29. 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

30. 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.

31. 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.

32. 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

33. THANKS FOR LISTENING
ANY QUESTIONS?

34. References
Paediatric Guidelines , Bedside Clinical Guideline Partnership