Fever in under 5s : assessment and initial management.
Identify life threatening features Airway Breathing Circulation Decreased level of consciousness Think if this could be SEPSIS
Fever- Oral and rectal routes not recommended by NICE Infants < 4 weeks – use electronic thermometer in axilla 4 weeks to 5 yrs use any ○ electronic thermometer in axilla ○ chemical dot thermometer in axilla ○ infra-red tympanic thermometer
Fever control Antipyretics do not prevent febrile convulsions and are not recommended by NICE to be used specifically for this purpose Not recommended ○ tepid sponging ○ under-dressed or over-wrapped If child distressed consider using Ibuprofen or Paracetamol ○ continue as long as the child is distressed ○ consider changing to another agent if distress is not elevated ○ Do not give both together ○ only consider alternating if the distress persists or recurs before the next dose is due NICE does not recommend using antipyretics with the sole aim of reducing body temp om children with fever
NICE traffic light system – Use NICE traffic light system to identify risk of serious illness Suggest print a copy – available in colour and put on your wall Keep a laminated copy if you locum. In children with learning disabilities – take that into account when interpreting the traffic light table Measure and record ○ temp ○ Heart rate ○ Resp rate ○ CRT Measure BP if HR or CRT is abnormal and you have facility to do that In children > 6 months- do not use height of body temp alone to identify those with serious illness
Dehydration – prolonged CRT abnormal skin turgor abnormal resp pattern weak pulse cool extremities.
Red – high risk pale / mottled / ashen / blue skin , lips or tongue no response to social clues appearing ill to a healthcare professional does not wake or if aroused does not stay awake weak high- pitched or continuous cry grunting RRate > 60 /min Moderate or severe chest drawing Reduced skin turgor Bulging fontanelle.Children younger than 3 months with a temp of 38° C or higher are in a high risk group for serious illnessIf life threatening illness suspected- refer for emergency medical care using 999 If any red feature but not considered to be life threatening – refer urgent paediatrics
Amber –pallor of skin , kips , tongue reported by parent or carer not responding normally to social clues no smile wakes only with prolonged stimulation decreased activity nasal flaring dry mucous membranes poor feeding in infants reduced urine output rigors.CRT of 3 s or longer in an intermediate risk group marker for serious illness Children 3-6 months with fever 39° C or higher are in intermediate group Children with tachycardia are in intermediate group.Amber but no red feature- should be assessed in a face to face setting Urgency of assessment will be determined by clinical judgment of the H/C professional carrying out the remote assessmentIf any amber feature present and no diagnosis reached - ○ safety net OR ○ refer paeds for further assessment Safety net should be 1 or more of ○verbal and or written information on warning symptoms and how further healthcare can be assessed ○ arranging further f/u at a specified time and place ○ liaising with other agencies including OOH to ensure direct access if further assessment is required
Green low risk- normal colour of skin, lips and tongue responds normally to social clues content / smiles stays awake or wakens quickly strong normal cry or not crying normal skin and eyes moist mucous membranes.Can be cared for at home with appropriate advice for parents and carers Also include advice on when to seek further attention
Triage-Remote triaging – use traffic light system and symptoms suggestive of specific disease.Life threatening illness suspected- refer immediately for emergency medical care usually 999 ambulance Any red feature but not considered to have a life threatening illness -arrange a face to face assessment within 2 hrs
References Fever in under 5s : assessment and initial management ( 2013 updated 2017 ) NICE guideline CG 160 https://pathways.nice.org.uk/pathways/fever-in-under-5s