Sepsis risk stratification for children younger than 5 years
Questionnaire/history:
Hx from?
Onset and pattern of fever?
- >48 hours?
- ≥ 5 days?
- Responding to paracetamol/ibuprofen within 30 min.?
Temperature objectified with fever thermometer?
- Infra-red tympanic thermometer?
- Electronic thermometer in the axilla?
- Chemical dot thermometers in the axilla (not recommended for healthcare professional)?
- Forehead thermometer (not recommended)?
- Oral route (not routinely recommend for children 0-5 years)?
- Rectal route (not routinely recommend for children 0-5 years)?
Max. temperature?
Associated symptoms?
- Runny nose?
- Cough?
- Continuous cough (a lot, for more than an hour or 3 or more coughing episodes in 24 h)?
- Vomiting?
- Diarrhoea?
- Shaking or exaggerated shivering (rigors)?
- Leg pain (NG 51)
- Cold hands and feet (NG 51)?
Feeding?
- ≤ 50% of normal intake?
Reduced urine output?
- ≤ 50% than usual or no wet nappy/wee for 12 h?
Past medical history?
- Premature?
- Perinatal complications?
Immunisation history (incl. missed immunisations)?
Recent foreign travel?
Recent contact with people with infectious diseases (eg COVID-19)?
Current medication?
Recent antipyretic drug(s)?
Recent antibiotic use?
Drug allergies?
Examination:
Behaviour?
- Responds normally to social cues, content, smiles, stays awake or awakens quickly, strong normal cry/not crying?
- Not responding normally to social cues, no smile, wakes only with prolonged stimulation, decreased activity, parent/carer concern that behaving differently from usual?
- No response to social cues, appears ill (to a healthcare professional), does not wake or if aroused does not stay awake, weak, high-pitched or continuous cry?
Colour (of skin, lips and tongue)?
- Normal?
- Palor of skin, lips or tongue?
- Pale, mottled, ashen or blue?
Temperature?
- ≥ 38°C (age < 3 months)?
- ≥ 39°C (age 3-9 months)?
- < 36°C (any age)?
Breathing?
- Normal?
- Nasal flaring?
- Grunting?
- Apneoa (NG 51)?
- Moderate or severe chest indrawing?
- RR > 50 bpm (6-12 months), > 40 bpm (>1 year)
(- RR 50-59 bpm (< 1 year), 40-49 bpm (1-2- years), 35-39 (3-4 years) (NG 51))?
- RR > 60 bpm
(- RR ≥ 60 bpm (< 1 year), ≥ 50 (1-2- years), ≥ 40 (3-4 years), < 60 bpm (any age) (NG 51))?
- Crackles in the chest?
- SpO2 < 95%?
- SpO2 < 92% (NG 51)?
- SpO2 < 90%?
Heart rate?
HR normal?
- HR > 160 bpm (< 1 year), > 150 bpm (1-2 years), > 140 bpm (2-5 years)?
(- HR 150-159 bpm (< 1 year), 140-149 bpm (1-2- years), 130-139 (3-4 years) (NG 51))?
HR ≥ 160 bpm?
(HR ≥ 160 bpm (< 1 year), ≥ 150 bpm (1-2- years), ≥ 140 (3-4 years) (NG 51))?
Regular?
Cor: H1+2+0?
Circulation and hydration?
- Eyes sunken in?
- Tears?
- Dry mucous membranes (lips and mouth not moist)?
- Cold hand or feet (NG 51)?
- CRT ≥ 3 seconds?
- Reduced urine output (NG 51)?
- Reduced skin turgor?
Other?
Abdomen?
- Abdomen distended?
- Abdomen soft?
- Apparent tenderness?
Other?
- Swelling of a limb or joint?
- Non-weight bearing limb/not using an extremity?
- Rigors?
- Non-blanching rash?
- Sunken anterior fontanelle (usually closed by 18 months)
- Bulging fontanelle?
- Neck stiffness?
- Focal neurological signs, focal seizures, status epilepticus?
Management:
According to cause
For home care:
Advised:
- To google + read online info 'High temperature (fever) in children - NHS', 'How to help your unwell child' and 'Advice for parents/carers during coronavirus'
- Paracetamol or/and ibuprofen (if no vomiting), to read package leaflet, particularly regarding dosage instructions
- To not underdress or over-wrap child
- To offer regular fluids and encourage a high fluid intake
- To check the child regularly, eg 2-4 hourly, including during the night (the frequency depending on the clinical situation)
- To keep the child away from nursery or school until they are recovered and to notify nursery or school about the illness
- To visit www.gov.uk to read about and follow the current coronavirus advice, particularly regarding self-isolation and testing
- To call 119 to arrange a Covid-19 PCR test if not already done
- For safety netting to call back or go to local paediatric A&E if new or worsening symptoms (eg more pale or mottled (blotchy) skin that feels unusually cold, crying for a long time despite distraction, confused, sleepy all the time, more rapid or difficult breathing, unable to keep fluids, rash that does not disappear when a glass is lightly pressed against the skin)
- To contact own GP for follow-up if no improvement or ongoing symptoms/concerns
Longer safety netting advice given:
To go straight to the nearest A&E or call 999 if:
- pale, mottled (blotchy) skin that feels unusually cold
- extremely distressed (crying for a very long time despite distraction), confused, sleepy all the time and difficult to wake up or not responding even
when awake
- severe breathing difficulty (eg breathing much faster than normal that too breathless to talk, eat or drink or long pauses in their breathing, irregular breathing, starts going blue)
- rash that does not disappear when a glass is lightly pressed against the skin
- fit
- if frightened because child looks very unwell
To immediately contact own GP and make an appointment for the child to be seen that day or call 111 as outlined in given recourses:
- quiet and lacking energy, even when the temperature is normal
- excessively sleepy or irritable (unable to settle with toys, TV, food or comfort), esp despite their temperature coming down
- crying constantly and you can't comfort or distract them, or the cry doesn't sound like their normal cry
- throaty noise when breathing
- 'grunting' noises with every breath
- finding it hard to breathe, including drawing in of the muscles at their neck, btw their ribs or below their lower ribs with sucking their stomach in under the rib cage
- can't say more than a few words at once (for older children who normally talk)
- obvious 'pauses' in their breathing
- not drunk anything for > 8 h (when awake)
- constant vomiting
- bright green, bloody or black vomit
- < 8 weeks + doesn't want to feed
- seems dehydrated (sunken eyes, drowsy, no wet nappy/wee for 12 h)
- < 2 year + bulging soft spot (fontanelle on their head)
- floppy
- constant of worsening abdominal pain
- extremely shivery or muscle pain without an obvious explanation
- < 3 months + T ≥ 38°C
- > 3 months + T ≥ 38°C that doesn't come down 15-30 min after paracetamol or ibuprofen
- 3-9 months + ≥ 39°C
- T < 36 three times within 10 min
- getting worse, more worried than now or concerned or distressed that unable to look after the child at home
To contact own GP for follow-up if no improvement or ongoing symptoms/concerns, particularly if fever (T ≥ 38°C) lasts for 5 days or longer
Reference(s):
NICE Clinical Guidance 143: Fever in under 5s: assessment and initial management
NICE CKS: Feverish children - risk assessment
NICE Guideline 51: Sepsis recognition, diagnosis and early management
Information for parents/carers:
Imperial College Healthcare: How to help your unwell child
Royal College of Paediatrics and Child Health (RCPCH): Advice for parents/carers during coronavirus
NHS Health A to Z: High temperature (fever) in children