Paediatric Acute care Guidelines PMH Emergency Department
  • Fever in a neonate is > 37.5oC
  • Fever in a child greater than 1 month old is > 38oC

Background

  • Fever is nature’s way of killing viruses/bacteria

General

  • Fever > 39oC in the 3-6 month age group is concerning as they are not fully immunised
  • After 6 months of age the height of the fever is unhelpful
  • Most fevers are caused by a viral illness
  • Lack of response to antipyretics does not predict a serious illness

Assessment

  • General features of the child’s behaviour, interaction and appearance over a period of time provide the best indicator of whether serious infection is likely
  • Beware of the unimmunised child
  • Beware of the partially treated child

Examination

  • A well child is one who is interested in their surroundings, interacts with caregivers and examines normally
  • A toxic child is :
    • Pale
    • Poorly perfused
    • Lethargic
    • Hypoventilation or tachycardia
  • For those children who are sick but not toxic use the traffic light system to stratify risk

System for Identifying the Likelihood of Serious Illness

  Low Risk  Medium Risk  High Risk 

Colour
Normal colour Pallor reported by parent/carer Pale/mottled/ashen/blue
Activity Responds normally to social cues
Content/smiles
Stays awake or awakens quickly
Strong normal cry/not crying
Not responding normally to social cues
No smile
Wakes only with prolonged stimulation
Decreased activity
No response to social cues
Appears ill to a healthcare professional
Does not wake or if roused does not stay  awake
Weak, high-pitched or continuous cry
Respiratory Normal parameters
No respiratory distress
Nasal flaring
SpO2 ≤ 95%
Crackles in chest
Tachypnoea
Grunting
Moderate or severe chest indrawing
Tachypnoea
Circulation and Hydration Normal skin and eyes
Moist mucous membranes
Tachycardia
Capillary refill time ≥ 3 seconds
Dry mucous membranes
Poor feeding in infants
Reduced urine output
Reduced skin turgor
Other None of the amber or red symptoms or signs Age 3-6 months, temperature ≥ 39°C
Fever for ≥ 5 days
Rigors
Swelling of a limb or joint
Non-weight bearing limb/not using an extremity
Age < 3 months, temperature ≥ 38°C
Non-blanching rash
Bulging fontanelle
Neck stiffness
Status epilepticus
Focal neurological signs
Focal seizures

Reference: NICE clinical guideline 160. Feverish illness in children. Assessment and initial management in children younger than 5 years. 2013

Normal Paediatric Values

See Emergency Calculator to view normal heart rate, respiratory rate and blood pressure values.

Management

Initial management

  • No tepid sponging
  • Treating fever with antipyretics is not recommended if the child is not miserable or in distress
  • Treat child for discomfort or pain with paracetamol or ibuprofen

Further management

Neonates with a temperature > 37.5ºC

FBC, U&E, CRP and blood cultures
Urine (SPA specimen)
Lumbar puncture
Consider CXR if indicated
Admit for IV antibiotics

1 month – 3 months of age with a temperature > 38ºC

FBC, U&E, CRP, blood cultures
Urine (catheter or SPA specimen)
Consider lumbar puncture (determined by clinical condition)
Consider CXR
Admit under General Paediatric Team for IV antibiotics

> 3 months of age with a temperature of > 38ºC

Sick looking child:

FBC, U&E, CPR, blood cultures
Urine (clean catch or catheter)
Consider lumbar puncture (determined by clinical condition)
Consider CXR
Admit under General Paediatric Team for IV antibiotics

Well looking child:

Obtain urine as per ED Guideline – Urinary Tract Infection 
Urine NOT required if obvious source of fever present

Unsure:

Use the Low,  Medium and High Risk system to assess and seek Senior Medical advice to guide investigations and treatment


Lumbar Puncture:

  • Consider if:
    • Toxic
    • Irritable
    • Umimmunised
    • Partially treated
    • Complex febrile convulsion that does not return to normal
  • For further information regarding lumbar punctures see ED Guideline –
    Lumbar Puncture

Chest X-Ray:

  • Usually only considered if signs of respiratory illness:
    • Cough
    • Increased respiratory rate
    • Creps or dullness on auscultation
    • Decreased oxygen saturations

Medications

Paracetamol

15 mg/kg 4-6 hourly
Maximum 60mg/kg/day for < 3 month old child
Maximum 80mg/kg/day for > 3 month old child

Ibuprofen

10mg/kg 6-8 hourly
Maximum 40mg/kg/day
To be given with food

Health information (for carers)

  • Fever does not cause brain damage
  • Use of antipyretics does not prevent febrile convulsions
  • Do not use antipyretics for more than 3 days without a General Practitioner review
  • Advise parents and document the features they need to look out for at home
  • Provide Health Fact Sheet: Fever in Children

Management paperwork

  • Document your clinical findings, both positive and relative negative

Nursing

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