Fever

Question 1

What are different ways to check temperature, and what is considered a fever for each? Which is GS?

Answer 1

• Axillary:
  ○ >37.2degrees
  ○ lower than other sites. Most accurate over axillary artery.
  ○ Usually used > 1mo
• Oral:
  ○ >37.5 degrees
• Rectal - GS:
  ○ >38 degrees
  ○ Usually <1mo
• Skin: forehead/axilla. Ambient temp may affect reading.

Question 2

What are the conditions you must rule out in fever in a child?

Answer 2

1. Meningitis
2. UTI/pyelonephritis
3. Pneumonia
4. Osteomyelitis
5. Septic arthritis
6. Septicaemia

Question 3

What is the risk of a serious bacterial infection in children <3 months with fever?

Answer 3

Risk is 20-30% in <3 months (cf 1.3% 3-12mo)

Question 4

Outline properties of low risk (green light) fever in children:

• Colour
• Activity
• Respiratory
• Hydration

Answer 4

• Normal colour
• Normal activity: responds to social cues, smiles, awake/awakens quickly, strong cry/not crying
• No amber/red resp signs
• Hydration ok

Question 5

Outline properties of mod risk (amber light) fever in children:

• Colour
• Activity
• Respiratory
• Hydration
• Other signs

Answer 5

• Pallor
• Abnormal activity: not responding normally, no smile, wakes with prolonged stimulation, dec activity
• Resp: nasal flaring, tachypnoea (6-12mo >50, >12mo >40), <95% O2sat, crackles
• Hydration: reduced urine output, CRT >3s, poor feeding, dry mucous membranes
• Other:
  ○ fever >/= 5 days
  ○ limb/joint swelling
  ○ NWB/not using a limb
  ○ new lump >2cm

Question 6

Outline properties of high risk (red light) fever in children:

• Colour
• Activity
• Respiratory
• Hydration
• Other signs

Answer 6

• Pallor/ashen/mottled/blue
• Abnormal activity: not responding normally, doesn’t wake/can’t stay awake, weak cry
• Resp: grunting, tachypnoea > 60 RR, chest indrawing
• Hydration: reduced skin turgor
• Other:
  ○ 0-3mo: T>38, 3-6mo: T>39
  ○ Non-blanching rash
  ○ Bulging fontanelle
  ○ Neck stiffness
  ○ Status epilepticus/focal seizures/neuro signs
  ○ Bile-stained vomiting

Question 7

When should an LP not be conducted?

Answer 7

• Impaired conscious state
• Focal neurological signs
• Haemodynamically unstable

Question 8

What does a full sepsis work-up entail

Answer 8

FBE/film, blood culture, urine culture (SPA), LP ± CXR

Question 9

Outline Mx for fever <1mo (corrected)/<3.5kg

Answer 9

• Full sepsis work-up: FBE/film, blood culture, urine culture (SPA), LP ± CXR
• Admit for empirical antibiotics

Question 10

Outline Mx for fever 1-3mo

Answer 10

• Full sepsis workup: FBE/film, blood culture, urine culture (SPA) ± CXR (only if respiratory symptoms or signs) ± LP
• Also: VBG, UEC

• D/C home with review within 12 hours if the child is:
	○ Previously healthy
	○ Looks well
	○ WCC 5,000- 15,000
	○ Urine microscopy clear
	○ CXR (if taken) clear
	○ CSF (if taken) negative

• If not: admit to hospital for observation +/- empiric i.v. antibiotics (flucloxacillin and gentamicin)

Question 11

Outline Mx for fever >3mo (corrected) with clear focus of infection

Answer 11

• if child looks well, treat as indicated

- if unwell, admit for Tx and Ix appropriately

Question 12

Outline Mx for fever >3mo (corrected) with NO clear focus of infection

Answer 12

child looks well:
• If < 12 mo boys or <2 yrs girls -urine (SPA up to 12mo, >12mo mcs)
• Discharge home on symptomatic treatment
• Arrange medical review within 24 hr, or sooner if deteriorates

child looks miserable but is still relatively alert, interactive and responsive
• If < 12 mo boys or <2 yrs girls -urine (SPA up to 12mo, >12mo mcs)
• Ix

child looks unwell:
• Full sepsis workup: FBE, blood culture, urine culture ± CXR (if respiratory symptoms or signs) ± LP
• Admit to hospital for observation +/- i.v. antibiotics

Question 13

When should we treat fever with paracetamol?

Answer 13

High temperature is not a good reason to treat fever unless prolonged and very high (> 40.5°C)

Question 14

What are some general measures for managing a fever at home? Advice for parents?

Answer 14

• Encourage fluid intake
• Cool kid down
  ○ Dress lightly
  ○ Tepid sponge on forehead only
• Don’t treat fever
• Return if worried