This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) with a febrile illness in Queensland.

This guideline aims to identify those infants and children at risk of serious bacterial infection or other significant illness who need timely treatment, while avoiding unnecessary investigations in the majority. The management of children with an unexplained fever for greater than one week or who have recently returned from overseas travel is beyond the scope of this guideline. For oncology patients refer to the Management of Fever in a Paediatric Oncology Patient Guideline.

This guideline has been developed by senior ED clinicians and Paediatricians across Queensland, with input from Infectious Disease specialist staff, Queensland Children’s Hospital, Brisbane. It has been endorsed for use across Queensland by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.

Fever is one of the most common paediatric ED presentations. Identifying a focus of infection can be challenging especially in very young children. While most children fully recover, infection remains the leading cause of death in children aged less than five years.

Definition

Fever is defined as a temperature greater than or equal to 38°C.

Pyrexia of unknown origin (PUO) refers to any fever lasting 10 – 21 days without a cause identified on history, examination and basic investigations and is beyond the scope of this guideline.

Measurement

In neonates (age less than 28 days) temperature should be measured using an electric thermometer in the axilla. For children over 28 days an infra-red tympanic thermometer may also be used. Forehead chemical thermometers are unreliable and not recommended.

A parent’s touch has been shown to have high sensitivity and low specificity for identifying a fever, however parental concern should be taken seriously.

Pathophysiology

Fever is a physiological response most often caused by an infective process, when exogenous pyrogens induce endogenous pyrogens, resulting in an elevated body temperature. The thermoregulatory centre then raises and maintains the body temperature to the new set point. This gives most children a degree of malaise and may negatively stress children with pre-existing cardiac, respiratory or neurological diseases. Fever is a generally beneficial adaptive response that promotes the immune response and inhibits the invading pathogen, potentially reducing the duration of certain infections.

Aetiology

In most children less than five years of age, fever is caused by a viral infection.¹

Less common causes include serious bacterial infection (SBI) such as urinary tract infection (UTI), pneumonia, bacteraemia, meningitis, or bone and joint infections, or conditions such as Kawasaki disease, vaccination reactions, arthritis, connective tissue disorders, malignancies, drug fever, or inflammatory bowel disease. The most common SBI in children is a UTI followed by pneumonia.

Post-vaccination fever is common with a typical onset within 24 hours of immunisation and duration of two to three days.

Teething does not cause fever greater than 38.5°C.

The aim of the assessment (history and clinical examination) is to identify children who:

• have a focus of infection (to enable appropriate investigations and, if needed, treatment)
• do not have an infective focus but require further investigation

History

Questioning should include specific information on:

• immunisation history
• immunosuppression (either by medical condition or treatment)
• history of fever and use of anti-pyretic
• current or recent antibiotic use
• recent overseas travel

This guideline also does not consider the approach to fever in the returned traveller – refer to Assessing fever in the returned traveller²

Age

Febrile infants aged less than three months have a higher risk of SBI, with the risk greatest in the neonatal period. Young infants are more likely to present with nonspecific features (they lack the hypothalamic and immune system maturity to localise the infection) and can deteriorate rapidly. Some infants less than three months may not mount a fever in response to SBI, and hypothermia or temperature instability can also be signs of SBI.

In addition to the pathogens seen in older children, Group B Streptococcus, E. Coli, Herpes Simplex virus, Listeria monocytogenes, Salmonella and Parechovirus infections are more common in neonates. Detecting other viral infections in children aged less than three months (most commonly RSV) lowers but does preclude a SBI.³ The estimated incidence of a UTI amongst infants less than three months with laboratory-confirmed RSV infection ranges from 3.3 to 5%.^4,5

Children aged between three months and three years who have their immunity boosted with vaccinations are at a lower risk of SBI than younger children. In this age group, the presence of a recognisable viral syndrome (including bronchiolitis) predicts a very low incidence of bacteraemia or SBI.

Children over three years of age have mature immune systems so are at a lower risk of SBI. The ability of older children to verbalise symptoms assists in identifying a focus of infection.

Immunisations and immune status

The Haemophilus influenzae type b (Hib) and pneumococcal immunisations have dramatically reduced the risk of occult bacteraemia and SBI. Children who have received at least two doses of the 13-valent conjugate pneumococcal (13vPCV) and Hib vaccinations (three dose course given as part of the National Immunisation Program at two, four and six months of age) have greater than 95% protection.

Children with congenital immune deficiency syndrome, sickle cell disease, HIV, asplenia, cancer, nephrotic syndrome, intracranial shunt, cochlear implant, immunosuppressive therapy or who are of Indigenous or Torres Strait Islander origin are at a greater risk for SBI, independent of vaccination status.

History of fever, prior antibiotic use and use of anti-pyretics

The height and duration of the fever and the response to antipyretics have failed to show any ability to differentiate severe from mild illness, or bacterial from viral infection.⁶

While not addressed within this guideline, consider a diagnosis of Kawasaki disease in children with a fever lasting more than five days.

Antibiotic therapy prior to presentation can mask the signs and symptoms of a bacterial illness.

Examination

The examination should identify a source for the fever if possible, and specifically assess for any signs of toxicity or early markers of the possibility of SBI.

Pay attention to concerns expressed by the caregiver, particularly any reported changes in usual behaviour.

Refer to the following guidelines as indicated:

• fever and respiratory symptoms in child aged less than 12 months – see Bronchiolitis Guideline
• fever and urinary symptoms – see UTI Guideline
• fever and severe localised joint pain – see Limp Guideline

Refer to the relevant guidelines if the following conditions are suspected:

• Sepsis
• Meningitis
• UTI
• Septic arthritis
• Bronchiolitis

Age three months or more

Most children aged three months or older who are fully immunised, have no comorbidities and appear well do not require extensive investigation. Refer to the flowchart for the approach to investigations in these children. A child with PUO may require more specialised investigations that are not included here.

Age less than three months

Refer to the flowchart for the approach to investigations in febrile infants aged less than three months.

Due to the higher risk of SBI and the challenges in reliable clinical assessment of toxicity in neonates (corrected age less than 29 days) a consistent approach to investigation is recommended, irrespective of clinical appearance.

Owing to the lower risk of SBI, infants aged 29 days to 3 months can be managed in a step-by-step approach with sequential evaluation of general appearance, urinalysis, and results of bloodwork.⁷ With careful clinical assessment, this approach allows identification of a group of infants at low risk of SBI who can be safely managed as outpatients without requiring a lumbar puncture or empiric antibiotics.

Additional investigations (e.g. serum electrolytes, glucose and venous blood gas) may be required based on the clinical presentation. Viral diagnostic studies are not routinely recommended to exclude a SBI.

Full blood count and risk of SBI

Despite being widely used, there is little evidence to support the use of a FBC in the risk stratification for well appearing, immunised children.¹⁰

A systematic review found WCC of no value in ruling out a SBI in immunised children and less valuable than CRP for ruling in SBI.¹¹ A prospective cohort study found that total WCC and absolute neutrophil count were not sufficiently accurate to be used as screening tests for febrile children with possible SBI.¹² For infants less than 60 days, no parameters on the FBC have been found to accurately predict the risk of a SBI.¹³

Meningococcal, salmonella and staphylococcal bacteraemias do not typically elevate the WCC.

The current NICE guidelines¹ use a WCC less than 5 x 10⁹/L or greater than 15 x 10⁹/L as risk factors for SBI in infants less than three months. Using an absolute neutrophil count of less than 10 x 10⁹/L in these infants has been validated as a reliable method of identifying those at low risk of SBI.⁷

For children who are not fully immunised, WCC may be a more reliable indicator of a SBI.

C reactive protein and risk of SBI

CRP is an acute phase reactant and concentrations start to rise four to six hours after the onset of inflammation and peak around 36 – 50 hours. CRP is better than the FBC for detecting SBI, especially if used after 12 hours of fever, however establishing a level of CRP which can reliably determine low risk of SBI is challenging. A systematic review found a CRP of greater than 80 mg/L was associated with a 72% risk of SBI, and a CRP or less than 20 mg/L with a 5% risk of SBI.¹¹ A more recent study suggested a CRP level of less than 20 mg/L in infants between 22-90 days identified infants at low risk of SBI.⁷ In the absence of a definitive cut off value, CRP should be only be used for screening on advice from senior clinicians and according to local practice.

Refer to the flowcharts for a summary of the recommended emergency management of febrile children less than three months and greater than or equal to three months. Management is based on the risk of SBI.

Supportive

Remove excess layers of clothing from the child. Over-enthusiastic physical cooling can be counterproductive by stimulating shivering and other heat-retaining reflexes. Oral fluids, if tolerated, should be encouraged to maintain hydration.

Antipyretics

Antipyretics may be prescribed for an awake child to provide relief from discomfort caused by the fever or the underlying cause of the fever. Educate parents regarding fever (immune system’s response to infection) and role of antipyretics (do not treat or shorten illness or prevent a febrile convulsion).

Avoid aspirin as the uncommon possibility of Reye’s syndrome increases with varicella or influenza-like illnesses.

There is some evidence to suggest that Ibuprofen reduces fever and discomfort faster than Paracetamol.¹⁴ While the popular dual therapy dosing regimens reduce the time with fever compared to monotherapy, there is no significant difference in resolution of discomfort.¹⁵ Alert parents to the safety concerns that have been raised over recommending two drugs with different dosing regimens for little gain.¹

A child with toxic features (see Assessment) or a purpuric rash (greater than 2 mm lesions) not consistent with typical Henoch-Schonlein purpura (HSP), should be managed presumptively for meningococcal disease with resuscitation as required and a third generation cephalosporin whilst investigations are conducted.

A well-appearing child with a fever and petechiae caused by local pressure or only in the distribution of the superior vena cava (e.g. following coughing/vomiting) may usually be discharged with early review.

The management of a non-toxic child with a fever and petechial rash that is not obviously mechanical or in the distribution of the superior vena cava, will depend on availability of senior/expert opinion, and the ability to observe the child over several hours. Refer to the flowchart as a guide to management. The role of blood tests in risk stratification as opposed to close serial clinical evaluation remains controversial, however documentation of a normal platelet count, collection of a blood culture, and consideration of risk stratification according to WCC and CRP are suggested. A WCC between 5-15 and CRP < 8 in the context of fever and petechial rash have been shown to have low risk of meningococcal disease, with these parameters being less reliable if the rash has been present for less than 12 hours.¹⁶ Risk stratification using this approach and an observation period of 4-6 hours has been shown to be safe.¹⁷

Refer to the guideline for sepsis, meningitis, UTI, septic arthritis and bronchiolitis as indicated.

Inter-hospital transfers

When to consider discharge from ED

Consider discharge ONLY on senior emergency/paediatric advice for:

• all febrile children aged 29 days to 3 months
• children aged 3 months or more with features of SBI who are not fully immunised

Consider discharge for children who meet ALL of the following criteria:

• no toxic features
• no other investigations or IV treatment required
• no features of SBI
• able to maintain adequate oral intake to maintain hydration
• can be safely managed at home and return in the event of deterioration (consider time of day, parent/carer comprehension and compliance, access to transport and distance to local hospital)

On discharge, provide parent/caregiver with a Fever fact sheet and advice to seek medical attention earlier if symptoms worsen or they have other concerns about their child’ health prior to their scheduled appointment.

Follow-up

• with GP within 24 – 48 hours to check progress and receive outstanding test results.

Follow-up must be arranged prior to discharge for children aged 29 days to 3 months.

When to consider admission

Admission is required for the following febrile children:

• suspected sepsis
• age less than 28 days
• need for ongoing management

Consider admission for the following children:

• age 29 days to 3 months (even if appear well may require longer period of observation)
• features suggestive of SBI
• inability to maintain adequate oral intake to maintain hydration
• unplanned return within 24 hours of initial assessment
• parents/caregivers unable to safely care for child at home and return in the event of deterioration

Guidelines

• Sepsis
• Meningitis
• Management of Fever in a Paediatric Oncology Patient
• Urinary Tract Infection
• Assessing fever in the returned traveller²

Factsheets

• Fever in children
• How to collect a clean urine specimen Factsheet

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