Fever in Under 5s: Assessment and Initial Management

This Guidelines summary includes recommendations for primary healthcare professionals on the assessment and management of fever in under 5s. Recommendations cover:

• using thermometers to detect fever
• assessing the risk posed by fever upon a child
• the traffic light system for identifying the risk of serious illness in a child with fever
• management by non-paediatric practitioners and in remote situations
• admission to hospital and referral to paediatric intensive care
• advice for home care and when carers should seek further help.

For a complete set of recommendations, refer to the full guideline.

This guideline replaces Clinical Guideline (CG) 160, and is the basis of Quality Standard (QS) 19 and QS64. It should be read in conjunction with CG102, CG54, CG84, and NICE Guideline 51.

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.Sepsis is a common condition of life-threatening organ dysfunction due to a dysregulated host response to infection.

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 2).
• 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.

Table 1: APLS Criteria for Tachycardia

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

Table 2: Traffic Light System for Identifying Risk of Serious Illness

• Refer to table 3 in the NICE guideline on sepsis if a child presents with fever and symptoms or signs that indicate possible sepsis. 
• 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.
• A colour version of this table is available.

Table 3: Summary Table for Symptoms and Signs Suggestive of Specific Diseases

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 3).

Management by Remote Assessment

Remote assessment refers to situations in which a child is assessed by a healthcare professional who is unable to examine the child because the child is geographically remote from the assessor (for example, telephone calls to NHS 111). Therefore, assessment is largely an interpretation of symptoms rather than physical signs. The guidance in this section may also apply to healthcare professionals whose scope of practice does not include the physical examination of a young child (for example, community pharmacists).

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 2 and 3.
• 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 (see the section on advice for home care).

Management by the Non-paediatric Practitioner

In this guideline, a non-paediatric practitioner is defined as a healthcare professional who has not had specific training or who does not have expertise in the assessment and treatment of children and their illnesses. This term includes healthcare professionals working in primary care, but it may also apply to many healthcare professionals in general emergency departments.

Clinical Assessment

• Management by a non-paediatric practitioner should start with a clinical assessment as described in the section on clinical assessment of children with fever. Healthcare practitioners should attempt to identify symptoms and signs of serious illness and specific diseases as summarised in tables 2 and 3.

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 (see the recommendation on advising parents or carers in the section on advice for home care)
  • 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 (see the section on advice for home care).

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 under 16s: diagnosis and management (NICE guideline 224).
• 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). See the NICE guideline on meningitis (bacterial) and meningococcal septicaemia in under 16s.

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 (see the recommendation on advising parents or carers in the section on advice for home care)
  • 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 (see the section on advice for home care).

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 as described in the section on antipyretic interventions in the full guideline.
• 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 5 days or longer
  • the parent or carer is distressed, or concerned that they are unable to look after their child.