Fever Assessment in Children

❍ Age-based risk stratification

Age is the primary risk-stratifying variable. Under 3 months: any fever ≥38°C requires same-day secondary care. Between 3 and 6 months: low threshold for same-day GP review for any fever ≥38°C. Over 6 months: structured clinical assessment using the NICE Traffic Light system can guide most management decisions in primary care.

The NICE Traffic Light system assesses five domains:¹

• Colour: pallor, mottling, or cyanosis (red); pallor reported by parent (amber); normal colour (green)
• Activity: no response to social cues, appears ill, weak or high-pitched cry (red); not responding normally, decreased activity (amber); responds normally, content, stays awake (green)
• Respiratory: grunting, saturations <92%, moderate-severe chest recession (red); tachypnoea, nasal flare, mild recession, SpO2 95-92% (amber); normal (green)
• Hydration: reduced skin turgor (red); dry mucous membranes, poor feeding, reduced urine output, capillary refill ≥3 s (amber); normal skin and eyes, moist mucous membranes (green)
• Other: non-blanching rash, bulging fontanelle, neck stiffness, focal neurology, limb swelling or non-weight bearing (red); fever >5 days, swollen limb or joint (amber); none of the above (green)

❍ Source identification

Systematically examine for source at every assessment: ears (otitis media), throat (pharyngitis, tonsillitis), skin (cellulitis, abscess), chest (pneumonia), abdomen (UTI, appendicitis), and joints (septic arthritis). A missed septic joint in a limping febrile child is a serious error.

Test urine in: any child under 3 years with unexplained fever lasting more than 48 hours; any girl under 5 with fever and no identified source; any uncircumcised boy under 1 year. A bag specimen is unreliable for culture - use clean-catch or catheter sampling if MC&S is required. A positive nitrite or leucocyte esterase on dipstick in a symptomatic child should prompt treatment while MC&S is awaited.

❍ Management and antipyretics

Antipyretics improve comfort and reduce distress; they do not reduce the risk of febrile convulsion and should not be given primarily to prevent one.³ Dosing is weight-based:

• Paracetamol: 15 mg/kg every 4-6 hours, maximum 4 doses per 24 hours
• Ibuprofen: 5-10 mg/kg every 6-8 hours (not under 3 months, use with caution in dehydration or renal impairment)

Alternating paracetamol and ibuprofen is common practice and generally safe; evidence for additive benefit over monotherapy is modest. Encourage oral fluids throughout. Advise parents that fever is part of a normal immune response and mild temperature elevation is not dangerous in itself.

Antibiotics by confirmed source: amoxicillin for AOM and non-severe community pneumonia; trimethoprim or nitrofurantoin for UTI (check local sensitivities); penicillin V or amoxicillin for streptococcal tonsillitis.

❍ Investigation guide

Investigations are guided by clinical risk category, not fever height. A well child over 3 months with a clear viral source and green features in all NICE Traffic Light domains requires no investigation.

In a child with amber features or unexplained fever without source: urine dipstick as minimum. FBC, CRP, and blood cultures are indicated for red features, all children under 3 months (in secondary care), and when the clinical picture remains uncertain after urine testing. Note: CRP rises over 12-24 hours and a normal result in the first 24 hours of fever does not exclude bacterial infection. Procalcitonin (where available) may be more sensitive within the first 12 hours.

Chest X-ray is not required to diagnose pneumonia clinically in most children. Request if SpO2 is low, respiratory examination is focal, or the child is failing to improve as expected.

❍ Referral thresholds and Kawasaki disease

Same-day secondary care (or 111 for non-blanching rash): under 3 months with any fever; any red NICE Traffic Light feature; non-blanching rash; suspected meningitis, encephalitis, or septic arthritis; SpO2 below 92% in air; significantly impaired feeding in an infant.

Same-day GP or urgent care: any child 3-6 months with fever ≥38°C; any amber NICE feature; fever with no source after assessment in a child under 2; parental concern in a child who has not improved as expected.

Fever persisting beyond 5 days in a child under 5 should prompt consideration of Kawasaki disease, particularly if accompanied by any of: bilateral non-purulent conjunctival injection, polymorphous rash, erythema/cracking of lips or strawberry tongue, erythema/oedema of hands and feet, cervical lymphadenopathy. Incomplete Kawasaki may present without the full classical criteria. Refer for echocardiography if suspected; coronary artery aneurysm is the principal complication.