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Febrile illness – Emergency

Febrile illness – Emergency management in children

Key points

  • Consider sepsis early in any patient with signs or symptoms that indicate possible infection.
  • Fevers in most children under five years of age have a viral aetiology and extensive investigation is not required.
  • Careful assessment will identify a focus on infection in most patients.
  • The recommended management of febrile infants and children without an evident focus of infection is guided by the risk of serious bacterial infection.
  • Neonates (age less than 28 days) and children who are not fully immunised are at greater risk of a serious bacterial infection.

Purpose

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.

Introduction

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.

Assessment

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.

Features of a toxic presentation
  • altered mental state
  • lethargy
  • inconsolable irritability
  • tachypnoea, increased work of breathing, grunt or weak cry
  • marked/persistent tachycardia
  • moderate to severe dehydration (feeding/urine output reduced by more than 50%)
  • poor perfusion (mottled cool peripheries, delayed central capillary refill)
  • seizures
Clinical features concerning for SBI
Feature What to look for on assessment
Pallor
  • ask parent if child is their usual colour
Decreased level of alertness
  • not smiling
  • less social interaction than is normal (ask parent)
  • decreased movement
  • sleepy
  • difficulty to wake
  • cry that is not strong
Moderate respiratory distress
  • nasal flaring
  • increased RR (over 50 bpm in child aged 6-12 months and over
    40 bpm in child over 12 months)
  • SpO2 <95% room air
  • crackles in chest
Decreased perfusion
  • sluggish capillary refill
  • poor feeding
  • persistent tachycardia
  • reduced urine output
Other
  • rigors
  • swelling of limb or joint
Differentiating toxic children from the wider group who are well but have a fever with appropriate physiological response can be challenging, especially in infants. Careful and repeated examination is essential.
Normal range for vital signs by age
Age Heart Rate (bpm) Minimum Systolic BP (mmHg) Respiratory Rate (bpm)
Term 100-180 60 40-60
6 months 100-180 70 30-50
1 year 100-170 70 20-40
2 years 100-160 70 20-30
4 years 80-130 75 20-30
8 years 70-110 80 16-25
12 years 60-110 90 16-25
16 years+ 60-100 90 10-16

Refer to the following guidelines as indicated:

  • ALERT – Consider sepsis in any patient with signs or symptoms that indicate possible infection. See Sepsis Guideline.
  • Seek urgent senior emergency/paediatric advice as per local practice for a child with fever and any of:
    • toxic features (in child of any age)
    • age less than 29 days
    • age 29 days to 3 months without typical respiratory illness

Investigations

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

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.

Investigations for the management of febrile illness in children
Investigation type Utility Notes
Urinalysis, microscopy and culture Recommended for the following children:

  • age less than 29 days
  • age 29 days to 3 months with no respiratory symptoms
  • age 3 months or older with no identified focus of infection who are
    • not fully immunised
    • fully immunised with fever for more than 48 hours

Consider for infants aged 29 days to 3 months with respiratory symptoms.

Method of collection is crucial – see table below.
See UTI Guideline for urinalysis interpretation.
Chest X-ray Consider for febrile child with cough and ANY of:

  • tachypnoea
  • SpO2 less than or equal to 93% in room air
  • increased work of breathing (chest recession, tracheal tug, use of accessory muscles)
  • temperature more than 39°C and WBC greater than 20 x 109 (as a screen for occult pneumonia).8
Cannot reliably distinguish viral from bacterial pneumonia9
Blood Culture Recommended for children with suspected bacteraemia.

Use lower threshold in young infants and unimmunised children especially if appear otherwise well due to higher bacteraemia rates and risk of septicaemia.

Contamination rate is often higher than true positive rate – careful attention to technique and larger blood volumes minimise contamination.

Culture sensitivity increases with blood volume. Recommended volume for aerobic culture:

  • 4 mL (green top bottle)
  • for neonates, 1 mL (yellow top bottle)

Collection of anaerobic blood culture is not needed.

Full blood count (FBC) Recommended for the following children:

  • age less than 29 days
  • age 29 days to 3 months with no respiratory symptoms
  • age 3 months or older, not fully immunised with no identified focus of infection
Must always be correlated with clinical findings. See further information below.
Lumbar Puncture (LP) Consider in the young febrile infant with nonspecific features such as vomiting, lethargy / drowsiness, irritability or poor feeding. Refer to Meningitis guideline.
Stool microscopy and culture Consider in the following children:

  • age less than 3 months infant with diarrhoea
  • mucoid, bloody or prolonged diarrhoea

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.

Urine collections methods in children
Collection method Utility Notes
Supra-pubic bladder aspiration (SPA)
  • age <6 months and toxic
  • phimosis or labial adhesion
  • invasive
  • gold standard as lowest contamination rate
  • success rate varies (23 – 90%) depending on operator, use of ultrasound and the presence of at least 20mL of urine
  • ultrasound significantly increases success rate
Urethral catheterisation (CSU) “in-out catheter”
  • age >6 months and toxic
  • age <6 months and toxic with failed SPA
  • non-urgent collection where CCU/MSU not possible/failed
  • invasive
  • low contamination rate
  • highest success rate
  • risk of iatrogenic infection
Clean catch specimen
  • non-urgent collection and unable to void on request
Midstream urine (MSU)
  • non-urgent collection and able to void on request
  • preferred method for toilet-trained children who can void on request
Bag specimens
  • not recommended
  • unacceptably high contamination rate so CANNOT be used for UTI diagnosis13

Management of fever

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.

Antipyretic dosing for the treatment of fever in children
Antipyretic Dose
Paracetamol (Oral) 15 mg/kg up to every four hours, maximum four doses in twenty-four hours
Ibuprofen (Oral) 10 mg/kg (maximum 400 mg) up to every six hours, maximum three doses in twenty-four hours

Avoid in children less than three months or if significantly dehydrated.

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

Management of fever with petechial rash

  • Seek senior emergency/paediatric advice as per local practice for unwell child with purpuric rash not consistent with Henoch-Schonlein purpura

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

Escalation and advice outside of ED

Clinicians can contact the services below to escalate the care of a paediatric patient as per local practices. Transfer is recommended if the child requires a higher level of care.

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

  • Critically unwell or rapidly deteriorating child

Includes children with the following (as a guide)
  • physiological triggers based on age (see below)
Less than 1 year 1-4 years 5-11 years Over 12 years
• RR >50
• HR <90 or >170
• sBP <65
• SpO2 <93% in oxygen or <85% in air
• GCS ≤12
• RR >40
• HR <80 or >160
• sBP <70
• SpO2 <93% in oxygen or <85% in air
• GCS ≤12
• RR >40
• HR <70 or >150
• sBP <75
• SpO2 <93% in oxygen or <85% in air
• GCS ≤12
• RR >30
• HR <50 or >130
• sBP <85
• SpO2 <93% in oxygen or <85% in air
• GCS ≤12
Reason for contact Who to contact
For immediate onsite assistance including airway management The most senior resources available onsite at the time as per local practices.
Options may include:

  • paediatric critical care
  • critical care
  • anaesthetics
  • paediatrics
  • Senior Medical Officer (or similar)
Paediatric critical care advice and assistance Onsite or via Retrieval Services Queensland (RSQ).
If no onsite paediatric critical care service contact RSQ on 1300 799 127:

  • for access to paediatric critical care telephone advice
  • to coordinate the retrieval of a critically unwell child

RSQ (access via QH intranet)
Notify early of child potentially requiring transfer.
Consider early involvement of local paediatric/critical care service.
In the event of retrieval, inform your local paediatric service.

  • Non-critical child

May include children with:
  • suspected SBI
  • purpuric rash not consistent with Henoch-Schonlein purpure
  • age less than three months, especially if considering discharge
  • no focus of fever evident but clinical concerns
Reason for contact Who to contact
Advice
(including management, disposition or
follow-up)
Follow local practices. Options:

  • onsite/local paediatric service
  • Queensland Children’s Hospital experts via Children’s Advice and Transport Coordination Hub (CATCH) on 13 CATCH (13 22 82)
    (24-hour service)
  • local and regional paediatric videoconference support via Telehealth Emergency Management Support Unit TEMSU (access via QH intranet) on 1800 11 44 14 (24-hour service)
Referral First point of call is the onsite/local paediatric service

Inter-hospital transfers

Do I need a critical transfer?
Request a non-critical inter-hospital transfer
Non-critical transfer forms

Disposition

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

Related documents

References

  1. National Institute for Health and Clinical Excellence. (2013, updated August 2017). Feverish illness in children. Assessment and initial management in children younger than 5 years’, [online] Available at: https://www.nice.org.uk/guidance/cg160
  2. Gherardin, A., Sisson, J. ‘Assessing fever in the returned traveller’. Aust Prescr 2012;35:10-4
  3. Byington, CL, Enriquez FR et al. Serious Bacterial Infection in Febrile Infants 1-90 days with and without viral infections. Pediatrics Jun 2004, 113 (6): 1662-1666
  4. Levine, DA, Platt SL et al. Risk of Serious Bacterial Infection in Young Febrile Infants with RSV infections. Pediatrics Jun 2004, 113 (6): 1728-1734
  5. Ralston S et al. Occult Serious Bacterial Infection in Infants younger than 60-90 days with bronchiolitis – a systematic review. Arch Pediatr Adolescent Med 2011;165 (10):951-956
  6. Teach, S.J., Fleisher, G.R. Duration of fever and its relationship to bacteremia in febrile outpatients 3 to 36 months old: the occult bacteremia study group.  Pediatr Emerg Care 1997;13(5):317–9.
  7. Gomez, B, Mintegi, S, Bressan, S et al. Validation of the “Step by Step” Approach in the Management of Young Febrile Infants. Pediatrics 2016; 138(2):e2015438
  8. American College of Emergency Physicians Clinical Policies Subcommittee. Clinical Policy for Well Appearing Infants and Children Younger than 2 Years of Age Presenting to the Emergency Department with Fever. Annals of Emergency Medicine May 2016; 67(5)
  9. Bettenay, F.A., de Campo, J.F., McCrossin, D.B.  Differentiating bacterial from viral pneumonias in children Pediatr Radiol. 1998;18(6): 453-454.
  10. De S, Williams GJ, Hayen A et al. Value of white cell count in predicting serious bacterial infection in febrile children under 5 years of age. Arch Dis Child 2014;99:493-499.
  11. Van den Bruel. Diagnostic value of laboratory tests in identifying serious infections in febrile children: systematic review. BMJ 2011;342: d3082.
  12. De S, Williams GJ, Hayen A et al. Value of white cell count in predicting serious bacterial infection in febrile children under 5 years of age. Arch Dis Child 2014; 99:493-499.
  13. Cruz AT, Mahayan P, Bonsu BK et al. Accuracy of Complete Blood Cell Counts to identify febrile infants 60 days or younger with invasive bacterial infections. JAMA Pediatr 2017;171(11): e172927
  14. Perrott, D.A., Piira, T., Goodenough, B., Champion, G.D. Efficacy and safety of acetaminophen vs ibuprofen for treating children’s pain or fever: a meta-analysis. Arch Pediatr Adolesc Med,2004;158(6): 521-6.
  15. Hay, A.D., Costelloe, C., Redmond, N.M. et al.  Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): randomised controlled trial. BMJ 2009;337: a1302
  16. Brogan PA, Raffels,A. The management of fever and petechiae: making sense of rash decisions. Arch Dis Child 2000;83:506-7)
  17. Riordan, F., Jones, L., Clark, J., et al. ‘Validation of two algorithms for managing children with a non-blanching rash’. Arch Dis Child 2016;101:709–713.

Guideline approval

Guideline approval history
Document ID CHQ-GDL-60006 Version no. 2.0 Approval date 26/09/2019
Executive sponsor Executive Director Medical Services Effective date 26/09/2019
Author/custodian Queensland Emergency Care of Children Working Group Review date 26/09/2022
Supercedes 1.0
Applicable to Queensland Health medical and nursing staff
Document source Internal (QHEPS) + External
Authorisation Executive Director Clinical Services (QCH)
Keywords Children; fever; febrile; temperature; emergency; management; paediatric; 00707; guideline, CHQ-GDL-60006
Accreditation references NSQHS Standards (1-8): 1, 8

Disclaimer

This guideline is intended as a guide and provided for information purposes only. View full disclaimer.
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