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Fever in under 5s: assessment and initial management

Thermometers and the detection of fever

Oral and rectal temperature measurements

  • Do not routinely use the oral and rectal routes to measure the body temperature of children aged 0–5 years

Measurement of body temperature at other sites

  • In infants under the age of 4 weeks, measure body temperature with an electronic thermometer in the axilla
  • 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
  • Healthcare professionals who routinely use disposable chemical dot thermometers should consider using an alternative type of thermometer when multiple temperature measurements are required
  • Forehead chemical thermometers are unreliable and should not be used by healthcare professionals

Subjective detection of fever by parents and carers

  • Reported parental perception of a fever should be considered valid and taken seriously by healthcare professionals

Clinical assessment of children with fever

Life-threatening features of illness in children

  • First, healthcare professionals should identify any immediately life-threatening features, including compromise of the airway, breathing or circulation, and decreased level of consciousness
  • Think ’Could this be sepsis?’ and refer to the NICE guideline on sepsis: recognition, diagnosis and early management if a child presents with fever and symptoms or signs that indicate possible sepsis

Assessment of risk of serious illness

  • 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, below)
  • When assessing children with learning disabilities, take the individual child’s learning disability into account when interpreting the traffic light table
  • Recognise that children with any of the following symptoms or signs are in a high-risk group for serious illness:
    • pale/mottled/ashen/blue skin, lips or tongue
    • no response to social cues
    • appearing ill to a healthcare professional
    • does not wake or if roused does not stay awake
    • weak, high-pitched or continuous cry
    • grunting
    • respiratory rate greater than 60 breaths per minute
    • moderate or severe chest indrawing
    • reduced skin turgor
    • bulging fontanelle
  • 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:
AgeHeart rate (bpm)
<12 months >160
12–24 months >150
2–5 years >140

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

 Green–low riskAmber–intermediate riskRed–high risk
Color (of skin, lips or tongue)
  • Normal colour
  • Pallor reported by parent/carer
  • Pale/mottled/ashen/blue
Activity
  • 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
Respiratory  
  • 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
Other
  • 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

Table 2: Summary table for symptoms and signs suggestive of specific diseases

Diagnosis to be consideredSymptoms 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
Pneumonia
  • 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
  • Assess children with fever for signs of dehydration. Look for:
    • prolonged capillary refill time
    • abnormal skin turgor
    • abnormal respiratory pattern
    • weak pulse
    • cool extremities

Symptoms and signs of specific illnesses

  • Look for a source of fever and check for the presence of symptoms and signs that are associated with specific diseases (see table 2, above)

Management by remote assessment

Management according to risk of serious illness

  • Healthcare professionals performing a remote assessment of a child with fever should seek to identify symptoms and signs of serious illness and specific diseases as summarised in tables 1 and 2
  • Children whose symptoms or combination of symptoms suggest an immediately life-threatening illness should be referred immediately for emergency medical care by the most appropriate means of transport (usually 999 ambulance)
  • 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
  • Children with ‘amber’ but no ‘red’ features should be assessed by a healthcare professional in a face-to-face setting. The urgency of this assessment should be determined by the clinical judgement of the healthcare professional carrying out the remote assessment
  • Children with ‘green’ features and none of the ‘amber’ or ‘red’ features can be cared for at home with appropriate advice for parents and carers, including advice on when to seek further attention from the healthcare services

Management by the non-paediatric practitioner

Clinical assessment

  • Management by a non-paediatric practitioner should start with a clinical assessment. Healthcare practitioners should attempt to identify symptoms and signs of serious illness and specific diseases as summarised in tables 1 and 2

Management according to risk of serious illness

  • Children whose symptoms or combination of symptoms and signs suggest an immediately life-threatening illness should be referred immediately for emergency medical care by the most appropriate means of transport (usually 999 ambulance)
  • Children with any ‘red’ features but who are not considered to have an immediately life-threatening illness should be referred urgently to the care of a paediatric specialist
  • 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 1 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
    • 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
  • Children with ‘green’ features and none of the ‘amber’ or ‘red’ features can be cared for at home with appropriate advice for parents and carers, including advice on when to seek further attention from the healthcare services

Tests by the non-paediatric practitioner

  • Children with symptoms and signs suggesting pneumonia who are not admitted to hospital should not routinely have a chest X-ray
  • Test urine in children with fever as recommended in urinary tract infection in children (NICE clinical guideline 54)
  • When a child has been given antipyretics, do not rely on a decrease or lack of decrease in temperature to differentiate between serious and non-serious illness

Use of antibiotics by the non-paediatric practitioner

  • Do not prescribe oral antibiotics to children with fever without apparent source
  • Give parenteral antibiotics to children with suspected meningococcal disease at the earliest opportunity (either benzylpenicillin or a third-generation cephalosporin)

Admission to and discharge from hospital

  • In addition to the child’s clinical condition, consider the following factors when deciding whether to admit a child with fever to hospital:
    • social and family circumstances
    • other illnesses that affect the child or other family members
    • parental anxiety and instinct (based on their knowledge of their child)
    • contacts with other people who have serious infectious diseases
    • recent travel abroad to tropical/subtropical areas, or areas with a high risk of endemic infectious disease
    • when the parent or carer’s concern for their child’s current illness has caused them to seek healthcare advice repeatedly
    • where the family has experienced a previous serious illness or death due to feverish illness which has increased their anxiety levels
    • when a feverish illness has no obvious cause, but the child remains ill longer than expected for a self-limiting illness
  • If it is decided that a child does not need to be admitted to hospital, but no diagnosis has been reached, provide a safety net for parents and carers if any ‘red’ or ‘amber’ features are present. The safety net should be 1 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
    • 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
  • Children with ‘green’ features and none of the ‘amber’ or ‘red’ features can be cared for at home with appropriate advice for parents and carers, including advice on when to seek further attention from the healthcare services

Referral to paediatric intensive care

  • Children with fever who are shocked, unrousable or showing signs of meningococcal disease should be urgently reviewed by an experienced paediatrician and consideration given to referral to paediatric intensive care
  • Give parenteral antibiotics to children with suspected meningococcal disease at the earliest opportunity (either benzylpenicillin or a third-generation cephalosporin)
  • Children admitted to hospital with meningococcal disease should be under paediatric care, supervised by a consultant and have their need for inotropes assessed

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

© NICE 2017. Fever in under 5s: assessment and initial management. Available from: www.nice.org.uk/guidance/CG160. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

First included: June 2013. Updated August 2017.