//////////////////When a child has been given antipyretics, do not rely on a decrease or lack of decrease in temperature at 1–2 hours to differentiate between serious and non-serious illness. Nevertheless, in order to detect possible clinical deterioration, all children in hospital with 'amber' or 'red' features should still be reassessed after 1–2 hours. [new 2013]

////////////////////////////Consider using either paracetamol or ibuprofen in children with fever who appear distressed. [new 2013]

//////////////////////////////1.6.3.2
Do not use antipyretic agents with the sole aim of reducing body temperature in children with fever. [new 2013]

//////////////////////////////////1.6.3.3

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. [new 2013]

Children with 'green' features and none of the 'amber' or 'red' features can be cared for at home with appropriate advice for parents and carers, including advice on when to seek further attention from the healthcare services (seesection 1.7). [2007, amended 2013]

///////////////////////GP=Children with 'green' features and none of the 'amber' or 'red' features can be cared for at home with appropriate advice for parents and carers, including advice on when to seek further attention from the healthcare services (seesection 1.7). [2007, amended 2013]

/////////////////////////When parenteral antibiotics are indicated for infants younger than 3 months of age, a third-generation cephalosporin (for example cefotaxime or ceftriaxone) should be given plus an antibiotic active against listeria (for example, ampicillin or amoxicillin). [2007]

////////////////////////////>3MO OLDS-Perform the following investigations in children with fever without apparent source who present to paediatric specialists with 1 or more 'red' features:

full blood count
blood culture
C-reactive protein
urine testing for urinary tract infection^[6]. [2013]

//////////////////////////////

Give parenteral antibiotics to:

infants younger than 1 month with fever
all infants aged 1–3 months with fever who appear unwell
infants aged 1–3 months with WBC less than 5 × 10⁹/litre or greater than 15 × 10⁹/litre. [2007, amended 2013]

///////////////////////////////

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

infants younger than 1 month
all infants aged 1–3 months who appear unwell
infants aged 1–3 months with a white blood cell count (WBC) less than 5 × 10⁹/litre or greater than 15 × 10⁹/litre. [2007, amended 2013]

Recognise that children with tachycardia are in at least an intermediate-risk group for serious illness. Use the Advanced Paediatric Life Support (APLS)^[1] criteria below to define tachycardia: [new 2013]

Age

Heart rate (bpm)

<12 months

>160

12–24 months

>150

2–5 years

>140

//////////////////////////

Management by the paediatric specialist

Perform the following investigations in infants younger than 3 months with fever:

full blood count

blood culture

C-reactive protein

urine testing for urinary tract infection^[2]

chest X-ray only if respiratory signs are present

stool culture, if diarrhoea is present. [2013]

//////////////////////////////

Antipyretic interventions

Antipyretic agents do not prevent febrile convulsions and should not be used specifically for this purpose. [2007]

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. [new 2013]

////////////////////////////TACHY >140, CRT >3 S

///////////////////////////

Kawasaki disease

Fever for more than 5 days and at least 4 of the following:

bilateral conjunctival injection

change in mucous membranes

change in the extremities

polymorphous rash

cervical lymphadenopathy

///////////////////////When assessing children with learning disabilities, take the individual child's learning disability into account when interpreting the traffic light table. [new 2013]

///////////////////////////Recognise that children with any of the following symptoms or signs are in a high-risk group for serious illness:

pale/mottled/ashen/blue skin, lips or tongue

no response to social cues^[3]

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. [new 2013]

/////////////////////////////////Recognise that children with any of the following symptoms or signs are in at least an intermediate-risk group for serious illness:

pallor of skin, lips or tongue reported by parent or carer

not responding normally to social cues^[3]

no smile

wakes only with prolonged stimulation

decreased activity

nasal flaring

dry mucous membranes

poor feeding in infants

reduced urine output

rigors. [new 2013]

////////////////////////////Recognise that children who have all of the following features, and none of the high- or intermediate-risk features, are in a low-risk group for serious illness:

normal colour of skin, lips and tongue

responds normally to social cues^[3]

content/smiles

stays awake or awakens quickly

strong normal cry or not crying

normal skin and eyes

moist mucous membranes. [new 2013]

////////////////////////////Recognise that a capillary refill time of 3 seconds or longer is an intermediate-risk group marker for serious illness ('amber' sign). [2013]

/////////////////////////In children older than 6 months do not use height of body temperature alone to identify those with serious illness. [2013]

////////////////////////Recognise that children younger than 3 months with a temperature of 38°C or higher are in a high-risk group for serious illness. [2013]

/////////////////////Recognise that children aged 3–6 months with a temperature of 39°C or higher are in at least an intermediate-risk group for serious illness. [new 2013]

////////////////////

Do not use duration of fever to predict the likelihood of serious illness. However, children with a fever lasting more than 5 days should be assessed for Kawasaki disease (see recommendation 1.2.3.10). [new 2013]

////////////////////////Consider bacterial meningitis in a child with fever and any of the following features^[5]:

neck stiffness

bulging fontanelle

decreased level of consciousness

convulsive status epilepticus. [2007, amended 2013]

////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////Consider urinary tract infection in any child younger than 3 months with fever^[6].[2007]

///////////////Consider urinary tract infection in a child aged 3 months or older with fever and 1 or more of the following^[6]:

vomiting

poor feeding

lethargy

irritability

abdominal pain or tenderness

urinary frequency or dysuria. [new 2013]

////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////[new 2013]

Children with fever and any of the symptoms or signs in the red column should be recognised as being at high risk.

1.1.2.2In children aged 4 weeks to 5 years, measure body temperature by one of the following methods:

electronic thermometer in the axilla

chemical dot thermometer in the axilla

infra-red tympanic thermometer. [2007]

1.1.2.3Healthcare professionals who routinely use disposable chemical dot thermometers should consider using an alternative type of thermometer when multiple temperature measurements are required. [2007]

1.1.2.4Forehead chemical thermometers are unreliable and should not be used by healthcare professionals. [2007]

1.1.3.1Reported parental perception of a fever should be considered valid and taken seriously by healthcare professionals. [2007]

1.2 Clinical assessment of children with fever

1.2.1.1First, healthcare professionals should identify any immediately life-threatening features, including compromise of the airway, breathing or circulation, and decreased level of consciousness. [2007]

1.2.2.1Assess children with feverish illness for the presence or absence of symptoms and signs that can be used to predict the risk of serious illness using the traffic light system (see table 1). [2013]

1.2.2.2When assessing children with learning disabilities, take the individual child's learning disability into account when interpreting the traffic light table. [new 2013]

1.2.2.3Recognise that children with any of the following symptoms or signs are in a high-risk group for serious illness:

pale/mottled/ashen/blue skin, lips or tongue

no response to social cues^[3]

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. [new 2013]

1.2.2.4Recognise that children with any of the following symptoms or signs are in at least an intermediate-risk group for serious illness:

pallor of skin, lips or tongue reported by parent or carer

not responding normally to social cues^[3]

no smile

wakes only with prolonged stimulation

decreased activity

nasal flaring

dry mucous membranes

poor feeding in infants

reduced urine output

rigors. [new 2013]

1.2.2.5Recognise that children who have all of the following features, and none of the high- or intermediate-risk features, are in a low-risk group for serious illness:

normal colour of skin, lips and tongue

responds normally to social cues^[3]

content/smiles

stays awake or awakens quickly

strong normal cry or not crying

normal skin and eyes

moist mucous membranes. [new 2013]

1.2.2.6Measure and record temperature, heart rate, respiratory rate and capillary refill time as part of the routine assessment of a child with fever. [2007]

1.2.2.7Recognise that a capillary refill time of 3 seconds or longer is an intermediate-risk group marker for serious illness ('amber' sign). [2013]

1.2.2.8Measure the blood pressure of children with fever if the heart rate or capillary refill time is abnormal and the facilities to measure blood pressure are available.[2007]

1.2.2.9In children older than 6 months do not use height of body temperature alone to identify those with serious illness. [2013]

1.2.2.10Recognise that children younger than 3 months with a temperature of 38°C or higher are in a high-risk group for serious illness. [2013]

1.2.2.11Recognise that children aged 3–6 months with a temperature of 39°C or higher are in at least an intermediate-risk group for serious illness. [new 2013]

1.2.2.12Do not use duration of fever to predict the likelihood of serious illness. However, children with a fever lasting more than 5 days should be assessed for Kawasaki disease (see recommendation 1.2.3.10). [new 2013]

1.2.2.13Recognise that children with tachycardia are in at least an intermediate-risk group for serious illness. Use the Advanced Paediatric Life Support (APLS)^[4] criteria below to define tachycardia: [new 2013]

Age

Heart rate (bpm)

<12 months

>160

12–24 months

>150

2–5 years

>140

1.2.2.14Assess children with fever for signs of dehydration. Look for:

prolonged capillary refill time

abnormal skin turgor

abnormal respiratory pattern

weak pulse

cool extremities. [2007]

1.2.3.1Look for a source of fever and check for the presence of symptoms and signs that are associated with specific diseases (see table 2). [2007]

1.2.3.2Consider meningococcal disease in any child with fever and a non-blanching rash, particularly if any of the following features are present^[5]:

an ill-looking child

lesions larger than 2 mm in diameter (purpura)

a capillary refill time of 3 seconds or longer

neck stiffness. [2007]

1.2.3.3Consider bacterial meningitis in a child with fever and any of the following features^[5]:

neck stiffness

bulging fontanelle

decreased level of consciousness

convulsive status epilepticus. [2007, amended 2013]

1.2.3.4Be aware that classic signs of meningitis (neck stiffness, bulging fontanelle, high-pitched cry) are often absent in infants with bacterial meningitis^[5]. [2007]

1.2.3.5Consider herpes simplex encephalitis in children with fever and any of the following features:

focal neurological signs

focal seizures

decreased level of consciousness. [2007]

1.2.3.6Consider pneumonia in children with fever and any of the following signs:

tachypnoea (respiratory rate greater than 60 breaths per minute, age 0–5 months; greater than 50 breaths per minute, age 6–12 months; greater than 40 breaths per minute, age older than 12 months)

crackles in the chest

nasal flaring

chest indrawing

cyanosis

oxygen saturation of 95% or less when breathing air. [2007]

1.2.3.7Consider urinary tract infection in any child younger than 3 months with fever^[6].[2007]

1.2.3.8Consider urinary tract infection in a child aged 3 months or older with fever and 1 or more of the following^[6]:

vomiting

poor feeding

lethargy

irritability

abdominal pain or tenderness

urinary frequency or dysuria. [new 2013]

1.2.3.9Consider septic arthritis/osteomyelitis in children with fever and any of the following signs:

swelling of a limb or joint

not using an extremity

non-weight bearing. [2007]

1.2.3.10Consider Kawasaki disease in children with fever that has lasted longer than 5 days and who have 4 of the following 5 features:

bilateral conjunctival injection

change in mucous membranes in the upper respiratory tract (for example, injected pharynx, dry cracked lips or strawberry tongue)

change in the extremities (for example, oedema, erythema or desquamation)

polymorphous rash

cervical lymphadenopathy

Be aware that, in rare cases, incomplete/atypical Kawasaki disease may be diagnosed with fewer features. [2007]

1.2.4.1When assessing a child with feverish illness, enquire about recent travel abroad and consider the possibility of imported infections according to the region visited.[2007]

[new 2013]

Children with fever and any of the symptoms or signs in the red column should be recognised as being at high risk. Similarly, children with fever and any of the symptoms or signs in the amber column and none in the red column should be recognised as being at intermediate risk. Children with symptoms and signs in the green column and none in the amber or red columns are at low risk. The management of children with fever should be directed by the level of risk.

This traffic light table should be used in conjunction with the recommendations in this guideline on investigations and initial management in children with fever.

A colour version of this table is available.

Green – low risk

Amber – intermediate risk

Red – high risk

Colour

(of skin, lips or tongue)

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

Nasal flaring

Tachypnoea: respiratory rate

>50 breaths/minute, age 6–12 months;

>40 breaths/minute, age >12 months

Oxygen saturation ≤95% in air

Crackles in the chest

Grunting

Tachypnoea: respiratory rate >60 breaths/minute

Moderate or severe chest indrawing

Circulation and hydration

Normal skin and eyes

Moist mucous membranes

Tachycardia:

>160 beats/minute, age <12 months

>150 beats/minute, age 12–24 months

>140 beats/minute, age 2–5 years

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

MILES TO READ B4 I SLEEP

Friday 12 July 2013

FEVER NICE NEW 2013