Paediatrics

The feverish child

Fever is a common, non-specific response that ranges from self-limiting viral illness to life-threatening sepsis; structured assessment of airway, breathing, circulation, behaviour, hydration, age and source of infection determines urgency.

In a nutshell

Assess every feverish child under 5 with ABCDE, the NICE traffic-light system and a search for the infection source. Temperature alone is not a severity score. Green children may go home with safety-netting; amber children need further assessment or planned follow-up; red features or high-risk sepsis criteria require urgent paediatric treatment.

Classic presentation

A child with fever is assessed for colour, activity, breathing, circulation, hydration, rash, age and source of infection before deciding on home care, observation, investigations or emergency treatment.

Key points

Temperature height alone does not distinguish serious from non-serious illness, and response to antipyretics must not be used to make that distinction.
Under 3 months with temperature 38°C or higher is high risk; 3 to 6 months with temperature 39°C or higher is at least intermediate risk.
Red features include mottled or ashen colour, cyanosis, unresponsiveness, grunting, severe chest indrawing, bulging fontanelle, non-blanching rash, focal seizures or status epilepticus.
In high-risk suspected sepsis, current NG254 requires senior review, indicated blood tests, monitoring and broad-spectrum antimicrobials without delay; do not give antibiotics to every low-risk fever without a source.
For 1-to-3-month-old infants with fever, parenteral antibiotics are guided by appearance and white-cell count; the old blanket rule for every apparently well infant is unsafe and obsolete.
Consider paracetamol or ibuprofen only when distressed; do not use them solely to lower temperature or prevent febrile convulsions.
Every child managed at home needs clear fluid, dehydration, worsening-illness and follow-up advice.

First-line investigation

ABCDE plus NICE traffic-light assessment, vital signs and focused examination for the source; urine and other tests are selected by age, risk and clinical question.

Management

Identify and stabilise red-flag illness

Use ABCDE; urgently transfer and treat children with airway, breathing or circulation compromise, reduced consciousness, shock, meningococcal signs, status epilepticus or high-risk sepsis criteria.^1,2,5,3

Risk-stratify and find the source

Record temperature, heart rate, respiratory rate and capillary refill, apply the traffic-light features, and examine for a focal infection, dehydration, rash or neurological signs.^1,2

Use targeted tests and supportive care

Select urine, blood, microbiology, imaging or CSF testing according to the risk category and clinical question; use antipyretics for distress and offer regular fluids.^1,5,4,3,7,8

Treat high-risk sepsis and serious infection

For high-risk suspected sepsis, obtain indicated samples, start broad-spectrum antimicrobials promptly, monitor closely and involve a senior clinician; follow meningitis and disease-specific pathways where indicated.^5,3

Discharge only with a safety net

Green children can be managed at home when carers receive clear advice on fluids, dehydration, worsening illness, non-blanching rash, fever lasting 5 days or more, fits and how to access urgent review.^1,9

Exam traps

A high temperature alone is not a sepsis diagnosis; clinical features and age determine risk.
A well-appearing child under 3 months with temperature 38°C or higher is still high risk and needs urgent paediatric assessment.
Do not wait for hypotension in paediatric shock; poor perfusion, tachycardia, tachypnoea and altered behaviour are earlier warnings.
Do not interpret a fall in temperature after paracetamol as proof that serious infection is absent.
Do not prescribe oral antibiotics for fever without an apparent source in a low-risk child.
Fever for 5 days or longer needs assessment for Kawasaki disease and other persistent causes.

Illustrations

NICE traffic-light tableReproduction of the green, amber and red traffic-light features for colour, activity, respiratory status, hydration and other signs used to risk-stratify a feverish child.PassFinals · original

Compensated versus decompensated shock in childrenDiagram showing progression from tachycardia and tachypnoea with preserved blood pressure to poor perfusion, hypotension and reduced consciousness in paediatric sepsis.PassFinals · original

Non-blanching rash assessmentIllustration of the glass test and the limitation that a non-blanching rash with fever requires urgent assessment rather than reassurance.PassFinals · original

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.