Febrile Child

Definition

• Fever is a body temperature above 38°C

• Use axillary measurement under 3 months, tympanic if over 3 months, ensuring correct technique

• Always consider adjusted age for premature infants when deciding investigations and management

History

• Assess risk factors such as recent travel, exposures to illness, immunisation status, antibiotic use, prematurity, and chronic or congenital conditions

• Explore symptoms of rash, feeding difficulties, decreased urine output, lethargy, or seizures

• Identify red flags including high-pitched cry, bulging fontanelle, neck stiffness, respiratory distress, prolonged capillary refill, poor feeding, or non-blanching rash

Red Flags

• Neurological signs such as altered consciousness, neck stiffness, bulging fontanelle

• Respiratory distress with increased work of breathing, tachypnoea, or desaturation

• Circulatory compromise including pallor, mottled skin, delayed capillary refill

• Poor feeding, dryness of mucous membranes, or reduced urine output

• Fever persisting beyond 5 days, refusal to bear weight, or a non-blanching rash

Investigations

• For any unwell child at any age, consider FBC, CRP, blood cultures, blood sugar, lactate, and potential CXR

• Urine testing is crucial, with SPA recommended under 1 month, SPA or catheter between 1 and 3 months, and clean catch for older children

• Lumbar puncture if meningitis is suspected, particularly in infants under 1 month or if there are concerning neurological signs

• UTI is the most common bacterial cause of fever in infants, so ensure adequate urine sampling when fever is unexplained

Management

• Under 1 month: Urgent referral to ED for full evaluation

• 1 to 3 months: Check urine culture for all fevers, admit if clinically unwell or showing red flags

• Over 3 months:

  • Observe if fever less than 24 hours without concerning features

  • Obtain urine culture if fever persists beyond 24–48 hours or in 3–12 months age group with fever >24 hours

• Supportive care with fluids, antipyretics (paracetamol 15 mg/kg, ibuprofen 10 mg/kg) for comfort

• Close follow-up within 24 hours if discharged, advising parents to return promptly if signs of deterioration occur

Notes

• Avoid lumbar puncture if raised intracranial pressure is suspected

• Suspected non-accidental injury necessitates involvement of child protection services

• Emphasise parental education on recognising signs of worsening illness and the importance of follow-up