A child with a fever – PEM Induction

Author & Questions: Frances Copp / Reviewer: Faathima Musaamil / Codes: / Published: 12/09/2018

Febrile children compete for the most common non-traumatic paediatric presentation in the Emergency Department (ED), causing concern for parents worldwide. Your mission: to find the source. This guide, by no means exhaustive, aims to talk you through a basic approach to assessment and management, with a reminder of those causes you really don’t want to miss.

Key points:

• Source is key. If you find a source, further investigation may not be necessary
• Look for signs of serious illness and suspect the ‘scary stuff’ in all children – that way you are less likely to be caught out
• Investigate as indicated, not as a routine
• Antibiotics are not always the answer
• If in doubt, a longer period of observation and a senior opinion never go amiss

FIRST IMPRESSIONS MATTER

Before even calling the patient’s name, take a moment to observe the child in the waiting room: How do they look? Charging around the play area with toy in hand? Subdued, super-glued to their guardian? Distressed? Unconscious? Posturing?

Whilst certainly not the only factor to be taken into account, much can be gleaned from a child’s level of activity and interaction with those around them particularly when trying to determine whether you are dealing with a septic child or yet another happy URTI. However, beware: younger infants may not respond as dramatically as older children to illness. In babies, particularly under 3 months of age, more nebulous indicators may be present – these may not be immediately evident.

First impressions can also be used as a reference point: if the child presents as grizzly, clingy and refusing fluids/food, with a fever and raised heart rate on initial observations, but an hour or two after administration of antipyretics you see before you a bouncing, interactive, feeding child with normal heart rate and settling temperature, you and the parents may be reassured. This may even be sufficient reassurance for discharge.

It is also worth remembering that first impressions go both ways. Approaching with a smile, getting quickly to their level (height and humour) and plying younger children with bubbles and distraction toys goes a long way to help you fully assess a child’s level of distress and gain trust from parents.

‘JUST A FEVER?’ TAKING A HISTORY: PARENTAL FEARS AND EXPECTATIONS

Frequently, parents exhibit ‘fever phobia‘: they are often concerned by the fever itself, the perceived degree of fever, regularity of fevers and the potential for fevers to continue to spiral with dangerous outcome. If specific concerns are uncovered early in the discussion – especially with any related parental experience – you may be guided towards any targeted reassurance and many of these fears may be abated. There are many myths surrounding fever and this resource aims to bust those myths.

Firstly, it can be helpful to explain to parents/ carers, that fever usually represents a natural response to infection and harm is rarely a direct result of the fever itself. Fever plays its part in the fight against infection, so advise them not to use antipyretic agents with the sole aim of reducing body temperature in children with fever. Explain to them that the use of anti-pyretics should be used to alleviate distress, ie to make their child feel less miserable, rather than to treat the temperature itself.

NICE provide advice on the use of anti-pyretics:

• Consider using either paracetamol or ibuprofen in children with fever who appear distressed
• 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

NICE² also states that tepid sponging is not recommended for the treatment of fever, nor should children with fever should be underdressed or over-wrapped.

It might be helpful here to note the confusion around the disputed value of temperature regarded as fever. The most common cut-off for defining a fever is 38 C. Some clinicians regard any value between 37.5-37.9 as low a grade fever. What is important is looking for the trend in the value. The specific value of the fever is usually irrelevant: higher temperatures (40-42 degrees Celsius) are not linked to tissue damage nor to the development of febrile seizures.

In infants under the age of 4 weeks, body temperature should be measured with an electronic thermometer in the axilla. In children aged 4 weeks to 5 years, body temperature can be measured by: electronic thermometer in the axilla, chemical dot thermometer in the axilla or infra-red tympanic thermometer. Forehead chemical thermometers are unreliable.

It is useful to delve into the history of the fever:

• Fever onset and duration: clarify if there are daily high temperatures and if there has been any break in the fever (and if so, for how long particularly important in presentations of over 5 days of fever).
• Any recorded temperatures at home (if normothermic on presentation). Occasionally parents will have a different idea of ‘fever’ to those clinically recognised.
• Associated febrile symptoms: Behaviour change with fever such as lethargy, off feeds/not drinking. Does this improve when fever settles? Have there been rigors or febrile seizures?
• Anti-pyretic use and response: regular use and, if so, paracetamol, ibuprofen or both, and at what dose? Always note the time of the last dose(s) given!
• Any focal infective symptoms?
• Rash? If so timing in relation to fever, where did it start and any spread?
• Oral intake and urine output – dehydration?
• Vaccination history
• Birth history particularly relevant in younger babies: Preterm? Special Care/ NICU admission? Perinatal complications? Maternal or neonatal antibiotics use? Premature rupture of membranes? Invasive group B streptococcal infection in a previous baby, or maternal group B streptococcal for the pregnancy of this child.
• Past medical history: any recurring infections? Immunocompromise? (usually volunteered early by parents)

Suspicion of more severe, or more specific, aetiology may be raised if any of the following are revealed:

• Recent travel abroad, or recent contact with travellers
• Contact with unwell individuals
• In the case of GI upset – suspicious food history and associated time frame: restaurants? Take-aways? BBQ? Others unwell with same symptoms from same event? Meat/fish?

It is also worth considering in the social history others who may be affected for example, any contact with immunocompromised individuals, pregnant women or young babies?

As with any good history, you will often be able to predict the source of the fever even if the child is unable to localise any symptoms. Be prepared to think laterally for example, if a child is refusing food and fluids could the source of fever be visible in the mouth or pharynx?

EXAMINATION – THE THREE E’s: ENT, EXPOSURE AND EXTREMITIES!

When examining the child, you are trying to look for the source of the fever. Don’t be afraid to expose fully to check for a rash and any inflammation around the genitalia. Wiggle joints for tone and tenderness and never, ever, forget ENT and lymph nodes! No child looks forward to a good tonsillar inspection and whilst this may be challenging, recruiting the parents and using distraction techniques will help you get the best view possible. Position is paramount. It’s worth leaving to the end of your examination, as you will probably make them cry! On your way in, make sure you take note of the appearance of the tongue and oral mucosa. The only exception to this would be if you have any suspicion of epiglottitis/severe croup in which case, further aggravation is best avoided

Be careful when looking for a rash: petechiae may be very subtle to begin with. Clarify the cause of any bruises with the child or parents. If you find petechiae, suspect Meningococcal infection. (Many trusts will have guidelines on the management Non Blanching Rashes). NICE also has a handy table for common features of specific diseases (see Table 3).²

Serios Illness?

NICE has a colour coded traffic light system to help identify serious illness in those under the age of 5.

Sepsis?

Remember children can also develop sepsis. Individual trusts will have their own sepsis screening tools and this is generally based on the appearance of the child and their observations. The UK Sepsis Trust has tools for different age groups. If sepsis is suspected, the paediatric sepsis 6 consists of:

1. Give high flow oxygen
2. Obtain IV/IO access and take blood tests (Blood gas and lactate (+/- FBC, U&E, CRP) Blood glucose treat hypoglycaemia, Blood cultures)
3. Give IV or IO antibiotics
4. Consider fluid resuscitation
5. Consider inotropic support early
6. Involve seniors/ Critical Care

Fever >5 days?

Kawasaki disease, should be considered in those with fever for >5 days. It is a systemic vasculitis that can result in cardiac disease and coronary aneurysms. It principally affects younger children (<5yrs) Features can include:

Figure 5: Table of Signs of Kawasaki Disease, adapted from NICE Guidelines ‘Fever in under 5s’

See RCEM learning module on Kawasaki Disease for more information.

If a child has had prolonged fever, and no features of Kawasaki, then ‘Pyrexia of Unknown Origin’ can be considered and this involves further investigation and discussion with the paediatric team.

‘DOCTOR, MY CHILD NEEDS A BLOOD TEST!’

In most circumstances, investigations are not needed if a source is identified. However, there are some instances when investigations are useful and or recommended.

It is always reasonable to check a bedside BM if lethargic or vomiting, particularly with a history of poor oral intake.

NICE provides recommendations of which investigations to perform based on age and the ‘traffic light’ features of the child with an unknown source of fever. However, in most circumstances, any child under 3 months with a fever will undergo a septic screen consisting of:

• Collecting FBC, CRP and blood cultures
• Urine testing for urinary tract infection (see NICE guidelines on how to interpret urine dips based on age)
• Chest X-ray only if respiratory signs are present
• Stool culture, if diarrhoea is present

Perform lumbar puncture in the following children with fever (unless contraindicated):

• Infants younger than 1 month
• All infants aged 1 to 3 months who appear unwell
• Infants aged 1 to 3 months with WBC less than 5 or greater than 15 10^9 per litre.

Investigations should be performed in any child with a suspicion of meningococcal infection or meningitis.

In those over the age of 3 months, with 1 red or 1 amber feature and no apparent source of fever, investigations should be considered.

Children in the ‘green’ group, with no apparent source of fever should have urine tested and be assessed for symptoms and signs of pneumonia. Chest X-rays are generally not recommended by the BTS guidelines, especially if the child is well enough to be discharged.
If the source remains unclear following the above basic testing, even if the child has no features of serious illness, discuss with your seniors/ general paediatric team, they may still need admission or a period of observation.

MISSION ACCOMPLISHED?

In most cases, a fever will be the result of a virus with clear localising signs. Rarely, other demons are at large. However, it is important to acknowledge that ‘just a virus’ may cause an otherwise well child to decompensate and therefore it is always necessary to be on the lookout for signs of compromise.

If you have found a source and feel your patient is well enough to head home, you may now be facing the antibiotic conundrum: to give or not to give? For this, bear in mind the question: ‘what am I treating and for whom?’ do not be swayed by parents if you feel antibiotics are not indicated! Stressing the relatively high risk of complications and likelihood of minimal impact on the course of illness is usually enough to dissuade any pro-antibiotic parents. The following poster from Edward Snelson’s gppaedstips blog site may also be of aid:

For many URTIs it is very difficult to distinguish between viral and bacterial causes however, if there is a possibility of secondary complication due to untreated bacterial infection (for example, streptococcal infection and Scarlet fever: exudative/inflamed tonsils, sandpaper rash, strawberry tongue), antibiotic cover should be carefully considered. Scoring systems can help towards this (for example, CENTOR score for likelihood of Streptococcal tonsillitis), although these also have their limits. The best approach is to treat the patient in terms of risk-benefit: if a child has severe or prolonged symptoms, complications, typical presentation for a particular antibiotic-susceptible pathogen, the reported 10% risk of complication from taking antibiotics may be outweighed by the benefits of their use. NICE gives guidelines on when to treat with antibiotics for: chest infections, otitis media and sore throat.

DISCHARGE LIKELY?

Should you decide that your patient is fit to go home, now is the time to further empower their parents in the management of fever. Explain what to expect in terms of symptoms, give advice regarding the use of anti-pyretics for comfort, advise regular fluids, and provide strong and specific safety netting for signs of worsening infection and dehydration. Remember, what you see now may not represent the patient later in the course of infection if any deterioration, parents must be encouraged to seek help.

References

1. Munro A. Hot Garbage: Mythbusting fever in children, Don’t Forget the Bubbles, 2020.
2. National Institute for Health and Care Excellence (NICE). Fever in under 5s: assessment and initial management. NG143. Last updated: 26 November 2021
3. National Institute for Health and Care Excellence (NICE). Traffic light system for identifying risk of serious illness in under 5s. 2019.
4. El-Radhi AS. Fever management: Evidence vs current practice. World J Clin Pediatr. 2012 Dec 8;1(4):29-33.
5. Brogan P, et al. Kawasaki Disease. BMJ Best Practice, 2022.
6. Harris M, Clark J, Coote N, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax 2011;66:ii1-ii23.
7. Paediatrics for Primary Care (and anyone else). Decision Fatigue and What to Do About It – When to Use Antibiotics for URTI, AOM and Tonsillitis in Children. 2018