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Feverish illness in children: assessment and initial management in children younger than 5 years

National Institute for Health and Care Excellence

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Key priorities for implementation

  • The following recommendations have been identified as priorities for implementation

Thermometers and the detection of fever

  • In children aged 4 weeks to 5 years, measure body temperature by one of the following methods:
    • electronic thermometer in the axilla
    • chemical dot thermometer in the axilla
    • infra-red tympanic thermometer
  • Reported parental perception of a fever should be considered valid and taken seriously by healthcare professionals

Clinical assessment of the child with fever

  • Assess children with feverish illness for the presence or absence of symptoms and signs that can be used to predict the risk of serious illness using the traffic light system (see table 1, right)
  • Measure and record temperature, heart rate, respiratory rate and capillary refill time as part of the routine assessment of a child with fever
  • Recognise that children with tachycardia are in at least an intermediate-risk group for serious illness. Use the Advanced Paediatric Life Support (APLS)* criteria below to define tachycardia:
Age Heart rate (bpm)
< 12 months >160
12–24 months >150
2–5 years >140

Management by remote assessment

  • Children with any ‘red’ features but who are not considered to have an immediately life threatening illness should be urgently assessed by a healthcare professional in a face-to-face setting within 2 hours

Management by the non-paediatric practitioner

  • If any ‘amber’ features are present and no diagnosis has been reached, provide parents or carers with a ‘safety net’ or refer to specialist paediatric care for further assessment. The safety net should be one or more of the following:
    • providing the parent or carer with verbal and/or written information on warning symptoms and how further healthcare can be accessed (see When to seek further help, below)
    • arranging further follow-up at a specified time and place
    • liaising with other healthcare professionals, including out-of-hours providers, to ensure direct access for the child if further assessment is required

Management by the paediatric specialist

  • Perform the following investigations in infants younger than 3 months with fever:
    • full blood count
    • blood culture
    • C-reactive protein
    • urine testing for urinary tract infection
    • chest X-ray only if respiratory signs are present
    • stool culture, if diarrhoea is present

Table 1: Traffic light system for identifying risk of serious illness

Children with fever and any of the symptoms or signs in the red column should be recognised as being at high risk. Similarly, children with fever and any of the symptoms or signs in the amber column and none in the red column should be recognised as being at intermediate risk. Children with symptoms and signs in the green column and none in the amber or red columns are at low risk. The management of children with fever should be directed by the level of risk. This traffic light table should be used in conjunction with the recommendations in this guideline on investigations and initial management in children with fever.

  Green–low risk Amber–intermediate risk Red–high risk
Color (of skin, lips or tongue)
  • Normal colour
  • Pallor reported by parent/carer
  • Pale/mottled/ashen/blue
  • Responds normally to social cues
  • Content/smiles
  • Stays awake or awakes quickly
  • Strong normal cry/not crying
  • Not responding normally to social cues
  • No smile
  • Wakes only with prolonged stimulation
  • Decreased activity
  • No response to social cues
  • Appears ill to a healthcare professional
  • Does not wake or if roused does not stay awake
  • Weak, high-pitched or, continuous cry
  • Nasal flaring
  • Tachypnoea—respiratory rate:
    • >50 breaths/minute, age 6–12 months
    • >40 breaths/minute, age >12 month
  • Oxygen saturation ≤95% in air
  • Crackles in the chest
  • Grunting
  • Tachypnoea—respiratory rate >60 breaths/minute
  • Moderate or severe chest indrawing
Circulation and hydration
  • Normal skin and eyes
  • Moist mucous membranes
  • Tachycardia:
    • >160 beats/minute, age <12 months
    • >150 beats/minute, age 12–24 months
    • >140 beats/minute, age 2–5 years
  • Capillary refill time ≥3 seconds
  • Dry mucous membranes
  • Poor feeding in infants
  • Reduced urine output
  • Reduced skin turgor
  • None of the amber or red symptoms or signs
  • Age 3–6 months, temperature ≥39°C
  • Fever for ≥5 days
  • Rigors
  • Swelling of a limb or joint
  • Non-weight bearing limb/not using an extremity
  • Age <3 months, temperature ≥38°C
  • Non-blanching rash
  • Bulging fontanelle
  • Neck stiffness
  • Status epilepticus
  • Focal neurological signs
  • Focal seizures

Summary table for symptoms and signs suggestive of specific diseases

Diagnosis to be considered Symptoms and signs in conjunction with fever
Meningococcal disease
  • Non-blanching rash, particularly with 1 or more of the following:
    • an ill-looking child
    • lesions larger than 2 mm in diameter (purpura)
    • capillary refill time of ≥3 seconds
    • neck stiffness
Bacterial meningitis
  • Neck stiffness
  • Bulging fontanelle
  • Decreased level of consciousness
  • Convulsive status epilepticus
Herpes simplex encephalitis
  • Focal neurological signs
  • Focal seizures
  • Decreased level of consciousness
  • Tachypnoea (respiratory rate >60 breaths/minute, age 0–5 months; >50 breaths/minute, age 6–12 months; >40 breaths/minute, age >12 months)
  • Crackles in the chest
  • Nasal flaring
  • Chest indrawing
  • Cyanosis
  • Oxygen saturation ≤95%
Urinary tract infection
  • Vomiting
  • Poor feeding
  • Lethargy
  • Irritability
  • Abdominal pain or tenderness
  • Urinary frequency or dysuria
Septic arthritis
  • Swelling of a limb or joint
  • Not using an extremity
  • Non-weight bearing
Kawasaki disease
  • Fever for more than 5 days and at least 4 of the following:
    • bilateral conjunctival injection
    • change in mucous membranes
    • change in the extremities
    • polymorphous rash
    • cervical lymphadenopathy

Antipyretic interventions

  • Antipyretic agents do not prevent febrile convulsions and should not be used specifically for this purpose
  • When using paracetamol or ibuprofen in children with fever:
  • continue only as long as the child appears distressed
  • consider changing to the other agent if the child’s distress is not alleviated
  • do not give both agents simultaneously
  • only consider alternating these agents if the distress persists or recurs before the next dose is due

Advice for home care

  • Care at home:
    • advise parents or carers to manage their child’s temperature
    • advise parents or carers looking after a feverish child at home:
      • to offer the child regular fluids (where a baby or child is breastfed the most appropriate fluid is breast milk)
      • how to detect signs of dehydration by looking for the following features:
        • sunken fontanelle
        • dry mouth
        • sunken eyes
        • absence of tears
        • poor overall appearance
      • to encourage their child to drink more fluids and consider seeking further advice if they detect signs of dehydration
      • how to identify a non-blanching rash
      • to check their child during the night
      • to keep their child away from nursery or school while the child’s fever persists but to notify the school or nursery of the illness
  • When to seek further help:
    • following contact with a healthcare professional, parents and carers who are looking after their feverish child at home should seek further advice if:
      • the child has a fit
      • the child develops a non-blanching rash
      • the parent or carer feels that the child is less well than when they previously sought advice
      • the parent or carer is more worried than when they previously sought advice
      • the fever lasts longer than 5 days
      • the parent or carer is distressed, or concerned that they are unable to look after their child

* Advanced Life Support Group (2004) advanced paediatric life support: the practical approach (4th edn). Wiley-Blackwell.
† See Urinary tract infection in children, NICE clinical guideline 54 (2007).


full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT

National Institute for Health and Care Excellence. Feverish illness in children. Assessment and initial management in children younger than 5 years . May 2013
First included: Jun 13.

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