Fever in under 5s/sepsis risk stratification/cough/breathlessness pathway in child

History/questionnaire:

Hx from:

Corrected age < 6 weeks? (RCPCH: Cough/breathlessness pathway for children ≥ 1 year of age)

Fever?

Onset (date and time when the fever was first noticed)?

If measured, which type of thermometer was used?

- Electronic thermometer in the axilla (suitable for children less than 4 weeks of age)?

- Infra-red tympanic thermometer?

- Chemical dot thermometers in the axilla (not recommended for healthcare professional)?

- Infrared forehead thermometer or oral or rectal route (not recommended)?

If measured, which was the highest temperature and when?

What was the pattern of the fever (e.g. going down with paracetamol or ibuprofen within 30 minutes)?

How long did the fever last?

- ≥ 5 days (NG143)?

- Playing around, active and alert? (RCPCH: Strep A and scarlet fever)

Associated symptoms?

- Child complaining of any pain (Spontaneously or on questioning?, Where?)?

--- Sore throat? (RCPCH: Strep A and scarlet fever)

--- Headache?

--- Abdominal pain?

--- Severe muscle aches?

- Runny nose?

- Cough?

- Continuous cough (a lot, for more than an hour or 3 or more coughing episodes in 24 h)?

- Vomiting?

--- How many times in the last 24 hours?

--- Loose or watery stools?

--- Blood in the vomitus (how much)?

--- Dark green vomit? (RCPCH: Strep A and scarlet fever)

- Diarrhoea?

--- How many times in the last 24 hours?

--- Loose or watery stools?

--- Blood in the stools (how much)?

- Shaking or exaggerated shivering (rigors)? (NG143+51)?

- Extreme shivering and complaints of muscle pain? (RCPCH: Strep A and scarlet fever)

- Not tolerating fluids/repeated vomiting? (RCPCH: Cough/breathlessness pathway for children ≥ 1 year of age)

- Unable to swallow saliva? (RCPCH: Cough/breathlessness pathway for children ≥ 1 year of age)

- Reduced urine output? (NG143+51)

- Reduced fluid intake (50-75% of usual intake over previous 3-4 feeds) and < 1 year of age? (RCPCH: Cough/breathes pathway for children < 1 year of age)

- Marked reduced fluid intake (< 50% of usual intake over last 2-3 feeds and 1 year of age)? (RCPCH: Cough/breathes pathway for children < 1 year of age)

- Reduced urine output? (NG143+51)

--- Dry nappy for 12 hours or more? (RCPCH: Strep A and scarlet fever)

- A little bumpy like sand-paper rash that seems to spread on the chest, arms and legs? (RCPCH: Strep A and scarlet fever)

- Additional parental/carer support required? (RCPCH: Cough/breathlessness pathway for children ≥ 1 year of age)

- Sudden onset and parenteral concern about inhaled foreign body? (RCPCH: Cough/breathless pathway for children ≥ 1 year of age) feverPain score

- Fever (during previous 24 hours)?

- Purulence (pus on tonsils)?

- Attend rapidly (within 3 days after onset of symptoms)?

- Severely inflamed tonsils?

- No cough or coryza (inflammation of mucus membranes in the nose)? Past medical history?

- Born preterm/premature?

- < 35 weeks? (RCPCH: Cough/breathes pathway for children < 1 year of age)

- Perinatal complications (e.g. maternal fever)?

- Risk factors for severe disease? (RCPCH: Cough/breathessness pathway for children ≥ 1 year of age)

--- Known asthma?

--- Chronic lung disease?

--- Bronchiectasis/CF?

--- Immunodeficiencies?

--- Congenital lung disease?

Immunisation history (incl. missed immunisations)?

Recent foreign travel (which areas)?

Recent contact with people with infectious diseases (eg COVID-19)?

Covid-19 lateral flow test(s) (When?)?

Regular medication(s)?

Recent antipyretic drug(s)?

- Paracetamol (Calpol) (Time of last dose?)?

- Ibuprofen (Nurofen) (Time of last dose?)?

- Other (Name?, time of last dose?)?

Recent antibiotic use?

Drug allergies (which drug)?

Examination:

Behaviour?

- Responds normally to social cues, content or smiles, stays awake or awakens quickly, strong normal cry or not crying (NG143+51)?

- Not responding normally to social cues, no smile, wakes only with prolonged stimulation, decreased activity? (NG143+51)

- Decreased activity/lethargy? (RCPCH: Cough/breathlessness pathway for children ≥ 1 year of age)?

- Parent of carer concerned that child is behaving differently from usual? (NG51)\

- Drowsy (excessive sleepy) or irritable (unable to settle them with toys, TV, food or picking up) – especially if remain drowsy or irritable despite fever coming down? (RCPCH: Strep A and scarlet fever)

- No response to social cues, appears ill to a healthcare professional, does not wake or if aroused does not stay awake, weak/high-pitched/continuous cry? (NG143+51)

- Extremely agitated (RCPCH: Strep A and scarlet fever)

- Confused/very lethargic (difficult to wake up)? RCPCH: Strep A and scarlet fever)

- Floppy? (UKHSA)

Colour (of skin, lips and tongue)?

- Normal (NG143 +51)?

- Pallor reported by parent/carer? (NG143)

- Pallor of skin, lips or tongue? (NG51)

- Pale/pallor (RCPCH: Cough/breathlessness pathway for children < and ≥ 1 year of age)?

- Pale, mottled, ashen or blue? (NG143)

- Blue lips? (RCPCH: Strep A and scarlet fever)

- Abnormally cold to touch? (RCPCH: Strep A and scarlet fever)

- Mottled or ashen appearance? (NG51)

- Cyanosis of skin, lips or tongue? (NG51)

- Blue or grey colour? (RCPCH: Cough/breathessness pathway for children ≥ 1 year of age)

- Fine red rash feeling like sandpaper, typically first on the chest and stomach, rapidly spreading to other parts of the body? (UKHSA 2022)

- Flushed red face, but pale around mouth, flushed face may appear more ‘sunburnt’ on darker skin than lighter skin? (UKHSA 2022)

- White coating on the tongue which peels a few days later, leaving the tongue looking red and swollen (know as ‘strawberry tongue’)? (UKHSA 2022)

- Peeling skin on the fingertips, toes, and groin area, as the rash fades? (UKHSA 2022)

Temperature?

- ≥ 39°C (aged 3-6 months)? (NICE143+51)

- Fever (temperature of ≥ 38°C) for ≥ 5 days? (NICE143)

- Rigors? (NG143)

- ≥ 38°C (100.4° F) (aged < 3 months)? (NG143+51) - ≥ 38°C (100.4 °F)? (UKHSA 2022)

- < 36°C (any age)? (NG51)

Breathing?

- Nasal flaring? (NG143+51)

- Finding it hard to breathe (RCPCH: Strep A and scarlet fever)

- Laboured/rapid breathing or working hard to breathe – drawing in of the muscles at the neck, between the ribs or below the lower ribs (recession)? (RCPCH: Strep A and scarlet fever)

- Mild / moderate respiratory distress (RCPCH: Cough/breathlessness pathway for children < and ≥ 1 year of age)?

- Audible stridor on exertion/distress only (RCPCH: Cough/breathlessness pathway for children < and ≥ 1 year of age)?

- Grunting? (NG143+51)

- Audible stridor at rest? (RCPCH: Cough/breathlessness pathway for children < and ≥ 1 year of age)

- Moderate or severe chest indrawing? (NG143)

- Abdominal recession? (UKHSA)

- Severe respiratory distress? (RCPCH: Cough/breathlessness pathway for children < 1 year and ≥ 1 of age)

- Too breathless to talk/eat or drink? (RCPCH: Strep A and scarlet fever)

- Unable to complete sentences? (RCPCH: Cough/breathlessness pathway for children ≥ 1 year of age)

- Pauses in breathing (apneoa)? (NG 51)

- RR > 50 bpm (6-12 months), > 40 bpm (>1 year)? (NG143)

- RR > 50-59 bpm (< 1 year), 40-49 bpm (1-2- years), 35-39 (3-4 years)? (NG51)

- RR 50-70 bpm? (RCPCH: Cough/breathes pathway for children < 1 year of age)

- RR > 40 bprm (12-23 months), > 35 bpm (2-5 years), > 30 bpm (5-12 years), > 25 bpm (> 12 years)? (RCPCH: Cough/breathes pathway for children ≥ 1 year of age)

- RR > 60 bpm? (NG143)

- RR ≥ 60 bpm (< 1 year), ≥ 50 (1-2- years), ≥ 40 (3-4 years)? (NG 51)

- RR > 70 bpm (< 1 year)? (RCPCH: Cough/breathlessness pathway for children ≥ 1 year of age)

- RR > 10 bpm above amber levels? (RCPCH: Cough/breathlessness pathway for children ≥ 1 year of age)

- Crackles in the chest? (NG143)

- SpO2 < 96%? (NG143)

- SpO2 < 92%? (NG 51)

- SpO2 < 90%? (NG51)

Heart rate?

- HR > 160 bpm (< 1 year), > 150 bpm (1-2 years), > 140 bpm (2-5 years)? (NG143)

- HR 150-159 bpm (< 1 year), 140-149 bpm (1-2- years), 130-139 (3-4 years)? (NG51)

HR ≥ 160 bpm? (NG143)

HR ≥ 160 bpm (< 1 year), ≥ 150 bpm (1-2- years), ≥ 140 (3-4 years)? (NG 51)

Regular?

Cor: H1+2+0?

Circulation and hydration?

- Normal skin and eyes? (NG143)

- Moist mucous membranes? (NG143)

- Able to tolerate some fluids? (RCPCH)

- Passing urine? (RCPCH)

- Sunken eyes? (UKHSA)

- Few or no tears when crying? (UKHSA)

- Dry mucous membranes (lips and mouth not moist)? (NG143)

- Cold hands or feet? (NG 51)

- Very cold hands and feet? (RCPCH: Strep A and scarlet fever)

- Cold hands or feet in the absence of fever? (RCPCH: Cough/breathessness pathway for children < and ≥ 1 year of age)

- CRT ≥ 3 seconds? (NG143+51)

- Abnormally cold to touch? (RCPCH: Strep A and scarlet fever)

- Reduced skin turgor?

Other? Swollen glands in the neck (UKHSA 2022)?

Abdomen?

- Abdomen distended?

- Abdomen soft?

- Apparent tenderness?

- Painful, red swollen gland in the neck which is increasing in size? (RCPCH: Strep A and scarlet fever)

- Leg pain? (NG51)

- Swelling of a limb or joint? (NG143)

- Non-weight bearing limb/not using an extremity? (NG143)

- Sunken anterior fontanelle (usually closed by 18 months)? (UKHSA)

- Features of scarlet fever? (RCPCH: Strep A and scarlet fever)

- If recent scarlet fever and puffy face/eyelids, tea ‘coca-cola’ colured urine or a swollen, paintful joint? (RCPCH: Strep A and scarlet fever)

- Getting worse and parent(s) worried? (RCPCH: Strep A and scarlet fever)

- Rigors?

- Rash that does not disappear with pressure (non-blanching rash)? (NG143+51)

- Bulging fontanelle? (NG143)

- Neck stiffness? (NG143)

- Focal neurological signs, focal seizures, status epilepticus? (NG143)

- Fit/seizure (RCPCH: Strep A and scarlet fever)

- < 1 year: seizure? (RCPCH: Cough/breathessness pathway for children < 1 year of age)

Management:

Advised to take child to paediatric A&E department immediately by parent/taxi or calling 999 as most appropriate

Advised to take child to urgent treatment centre (UTC) for F2F assessment

Safety net advice given: - To google + read online info

--- 'My Surgery Website How to help your unwell child'

--- 'NHS Health A to Z: High temperature (fever) in children'

--- ‘Healthier Together Strep A and scarlet fever’

--- ‘Medicines for Children How to give different types of medicines’

- 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 arrange a Covid-19 test if not already done

- For safety netting to call back or go to local paediatric A&E if new or worsening symptoms (eg laboured/rapid breathing, not drinking at least 50% of usual intake, not passing urine within 12 h, crying for a long time despite distraction, pale or mottled (blotchy) skin that feels unusually cold, confused, sleepy all the time, difficult to be woken up)

- To contact own GP for follow-up if no improvement or ongoing symptoms/concerns

Reference(s):

1) NICE CKS: Feverish children - risk assessment

2) NICE Clinical Guidance 143: Fever in under 5s: assessment and initial management

3) NICE Guideline 51: Sepsis recognition, diagnosis and early management

4) RCPCH: Cough/breathless pathway in child < 1 year of age (remote assessment)

5) PCPCH: Cough/breathless pathway in child ≥ year of age (remote assessment)

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

Medicines for Children How to give different types of medicines

NHS Health A to Z: High temperature (fever) in children