Paediatrics: Fever
Fever is one of, if not the most common reason for parents/ guardians to seek medical attention for their children. It is often hugely concerning for parents and fever phobia is definitely a real phenomenon, with much misunderstanding surrounding this topic. However it is not just parents that get worried. Paramedics have often been taught that children compensate for a long time and then deteriorate quickly, that high fever indicates sepsis and that fever control is a must. There is much myth and blurred understanding of working up a child with a fever and this results in varying practices and approaches to management. Alongside this, a lack of solid paediatric education amongst some paramedics results in questionable understanding of differentiating the worrying sick child from the mild self-limiting illness. As a result high levels of conveyance of children with mild self-limiting conditions that could be managed, had that parent contacted another NHS service e.g. GP, without hospital admission. Much of this inappropriate conveyance is passed off as acceptable because it’s the 'safer option', however it has become used by some ambulance services to introduce mandatory conveyance policies for children under a certain age, ignoring the actual problem which needs fixing and that is how can we improve our training in paediatric urgent and emergency care. There is no quick fix for this but we must all take responsibility for our own education and seek out to improve our practice in the areas we may feel weaker in. Only this way can we one day remove these mandatory policies that inhibit the right care being delivered to our paediatric patients. This episode could be the first step in developing your knowledge of paediatrics and what better way than to learn from experts. That’s why this month we are learning all about paediatric fever with the help and guidance of Dr. Waj Khattam a consultant in Paediatrics so lets get stuck in to this 'HOT' topic.
Physiology:
Fever is an elevated core body temperature as part of a host regulated physiological response to infection, normally by viral or bacterial pathogens. An understanding that fever is physiological and a normal response from your body towards infection as opposed to something dangerous an infection is doing to your body, can be quite reassuring when thinking about this topic [1] . This is in stark contrast to pathological hyperthermia, where temperature is elevated due to hypothalamic dysfunction or external heat illness, hence the reason they are managed very differently.
Fever occurs as a result of the effects of Endogenous or exogenous pyrogens which signal the hypothalamus to increase the body's thermoregulatory set point. [2]. Endogenous pyrogens such as cytokines (IL1, TNF, Prostoglandin E2, IL6) are produced by our immune response in response to detection of invading organisms. Exogenous pyrogens come from the microbe itself such as the lipopolysaccharide on the outside of the bacteria. The pyrogens assert their effect by causing prostaglandin E2 to change the temperature set point of the hypothalamus. As a result various mechanisms begin to raise our body temperature for example, shivering due to acetylcholine release in the muscles, vasoconstriction peripherally to bring blood to the core, piloerection to trap air on the surface of the skin and warm seeking behaviours such as putting on clothes, wrapping up under layer etc.
We must remember that there are other non-infectious causes of fever such as cancer, Kawasaki's and autoinflammatory conditions, however these, with the exception of Kawasakis, will not be within the scope of this episode.
Although there is variations within the literature, fever is generally considered to be any temperature over of 38°C or higher [3].
Detecting Fever:
In infants under the age of 4 weeks, temperature should be recoded with an electronic thermometer in the axilla.
In children aged 4 weeks to 5 years, body temperature should be measured by either: infrared tympanic thermometer or electronic or chemical dot thermometer in the axilla.
Forehead chemical thermometers are unreliable and should not be used
Reported parental perception of fever should be considered valid and taken seriously by health care professionals. [4]
History
Fever is a vast topic and the specific questions in the history and what focused examination to perform is likely to vary and be dependant upon the direction the consultation is going. Developing skill in this area is needed and will come with experience of seeing paediatric patients.
Image From NICE Guideline NG143
However there are some general principles we want to consider and information that is essential to gather in order for us to decide on safe management plans specifically surrounding discharge vs conveyance. A good place to begin is by becoming familiar with the NICE guideline (NG143) Fever in under 5s: assessment and initial management. This guideline covers our youngest population and the most common presenters with fever and gives us a traffic light based system of green, amber and red flag features to consider. Much of the upcoming history and examination will be looking for or ascertaining the absence off these features.
As always, on the initial approach if a child looks unwell and big sick then begin an A-E and resuscitate as needed and gather information as you go along. However if a child is not immediately worrying you, we can take our time and gather a little more information from the parents whilst, starting to build rapport and trust with the child. Your consultation is likely to be more successful and a happier engagement for all involved (including ourselves) if this rapport and trust is built where possible.
It is often best to stand back and start just taking history from the parents, letting the child continue with their activities and getting used to your presence at the scene.
As always start with an open question e.g. Tell us about why you called today or tell us about (insert childs name here) and whats brought you to call today. Often parents will give you a considerable amount of information here.
We can then begin to close this down further with other questions, some examples of things that you need to consider are:
· Trying to get a chronological order from the parents of when symptoms developed over the course of the acute illness e.g. if fever, rash, cough and SOB are reported, which came first etc.
· When did the fever begin
· Duration of the fever (remember fever over 5 days is an amber feature and often needs further workup)
· Is there an objectively measured temperature and how was this recorded e.g. tympanic, chemical forehead scanner etc, or parental reports of the child feeling like they have fever.
· What height of fever if recorded has their been.
· Has the fever been there constantly or has it been up and down,
· Has there been antipyretic use,
· How has the child been in themselves with the fever or after antipyretics. Are they well, playing and happy despite the temp or grouchy, clingy and irritable or maybe swinging between the two.
· Enquire about associated symptoms (much of which will be dependant upon the age of the child and if they can report these features or are noticed by parents) (this list is not exhaustive just some examples):
o Rigours
o Drowsiness/ irritability/ floppiness
o SOB/ Recessions/ Apnoea’s/ Cough
o Coryza/ Sore throat/ Otalgia/ Otorhoea/
o Rash
o Neck pain/ stiffness, photophobia, headache
o Dysuria/ frequency
o Febrile Seizures
The associated symptoms are important as some of these features help us distinguish a possible source which is something we should be trying to identify.
Past medical history – we need to enquire about past medical history specifically surrounding any previous admissions to hospital with febrile illness or convulsions, risk factors/ conditions that may cause immunocompromise. We should enquire about congenital problems, complications at birth whether SCBU/NICU admission was needed. Was the child born at term or premature by vaginal or caesarean section. This is all information that can help feed into our impression. Premature births for example often suffer from under developed respiratory tracts, bringing a greater degree of infection risk. Patients with Cerebral palsy and some other syndromes may have a normally low resting body temp. so a fever may present as under 37.8 but technically be a fever for them.
Allergy status - This is something we need to ask and document. Allergic reaction could present with fever among other symtoms, so consider this.
Social History – Ask about who the child lives with, Older siblings often bring home viral illness and it’s a common story to be told about siblings being unwell. Ask about smoking in parents especially with respiratory causes of illness. Ask about social care involvement as this is a good screening question for all paediatrics. Document the names and ages of siblings of the child, as well as their pre-school or school, this is a good safeguarding practice to get into… make it a habit and you will thank yourselves later.
Family History – Especially with febrile seizure presentations we should enquire about siblings and if parents had febrile seizures as there is likely a genetic component to this.
The next step is the physical examination.
Examination
There are some simple steps here we can take to improve the experience for the children and our chance of success in getting a good examination.
Be opportunistic. Examination may not follow the same structure as adults, there may be things you can do at certain times easier than others, for example if a child is asleep, listen to their chest. You may have to apply a bag or ask a parent to sit with a specimen pot to get a clean catch of urine to do a urine dip.
With this in mind consider sitting back away from the child to begin and then try to get to down to their level, so we are not towering above them.
Consider using distraction techniques; blown up gloves with knots in, bubbles, toys and parents mobile phones/ tablets/ TVs with games and programs are all good ways of undertaking an examination. Your next bit of research if you’re not up to date with kids tv and crazes is to learn a little bit about the current 'coolest' thing e.g. paw patrol, peppa pig, dinosaurs (this was in when I wrote this….. but who knows what it will be when you read it 😊)
Save distressing examination and procedures till last e.g. ear and throat exams, especially throat. Blood sugars are another example, ask yourself does this need to be performed, if yes leave it until one of the last things done.
Use simple age appropriate language for verbal children, ask parents what words are used to describe things like pain or body parts so you communicate with the child when examining them.
A lot of examination can be done with observation so take time with the inspection phase. Some components of examination need to be modified to be age appropriate a cranial nerve exam for example.
In relation to what to include in your examination this is likely to vary depending on your history and can be focused. However often in children, especially younger children history is less significant than in older children and adults and examination takes a wider influence over diagnosis and decision making.
A good example of an approach to examining a child with a fever can be found in the online course spotting the sick child and is called the 3 minute tool kit [Home | Spotting the Sick Child]. We highly recommend anyone who feels their paediatric assessment needs improving to complete this free online course. However all younger children should have performed
General exam – including feeling lymph nodes, assessing hydration and perfusion. Expose down to skin level, this is important to examine for non-accidental injury and the presence of rashes. Consider is the rash blanching or non-blanching. Non-blanching rashes are often considered more serious and this is reflected within the NICE traffic light guidance in that it is a red flag. This is due to the risk of meningococcal disease/ sepsis, however there are other conditions such as petechia in the distribution of the Superior vena cava (above nipple line) post vomiting or violent coughing or Henoch-Schonlein purpura, a small vessel vasculitis in children, that can also give rise to non-blanching rashes. However treat as red flag and arrange further review by a senior clinician/ paediatrician which most likely will mean conveyance to the emergency department.
Respiratory - looking for increased work of breathing/ respiratory distress. Auscultating for chest sounds being aware that in smaller chests upper airway noises can be easily transmitted to sound as though coming from lower airways. Oxygen saturations and respiratory rate. Be aware that tachypnoea is the first sign of a child who is unwell and should never be ignored. A caveat however is that RR needs to be accurately recorded when the child is not crying/ distressed if possible and if high temp, after antipyretics to see if this has settled tom normal and is just a physiological response to the fever… tachycardia should be considered in the same way. Persistent tachycardia or tachypnoea is concerning and warrants further investigation. Also, look at the rhythm and depth to breathing. A prolongued expiratory phase can be an indicator of bronchoconstriction and the requirement for bronchodilators.
Cardiovascular – colour, touch temperature of the peripheries, looking for mottling, central capillary refill time, pulses (brachial/ femoral in younger children/ babies, radial in older children). Blood pressure if relevant although accepting it is a late sign of shock in children and likely will only be low once the child is beginning to decompensate. Listen for heart sounds + re call what we said above about tachycardia.
ENT – Nearly all children with fever need an ENT exam as this is often the source of URTI infections. Check behind the ears for mastoid swelling/ redness and tenderness to palpation, as suspected mastoiditis needs urgent management if found. This is where some gaps in examination skill may present. We should be learning and applying otoscopy. Check the external cannal for signs of discharge, pain, swelling and erythema indicative of otitis externa. Then look inside the ears for signs of otitis media a common presentation in children due to throat infections tracking up and blocking the eustachian tubes. Examine the throat (probably last in young children as its distressing) some older children will be able to open their mouths and follow instructions or you can play a game of getting them to roar like a lion or trying to lick their own chin, this should give a good view of the back of the throat in many children. Some children you will need a wooden tongue depressor to visualise. Its important to look for erythema of the pharynx, tonsillar enlargement, pus/ exudate on the tonsils and the red flags of peritonsillar abscess.
Abdominal exam – Children present commonly with abdominal symptoms and fever. Look for swellings/ masses/ bruises or distension visually. Offer analgesia early to children with abdominal pain as this may help facilitate examination. Listen for bowel sounds. Palpate lightly first before doing deeper palpation. Do not ask young children to tell you if things hurt as they will likely give you an answer they think you want to hear, instead distract them with chat about Paw patrol or Peppa pig etc. Whilst doing this distraction watch their face for signs of pain e.g. wincing, distressed expression, pushing your hand away whilst simultaneously feeling for guarding or rigidity. Assess deeper for masses or hepatosplenomegaly. Always check the hernial orifices as you do not want to miss an incarcerated hernia. Check the nappy area for signs of non-accidental injury or rashes. If indicated from the history consider testicular examination in boys for torsion or epididymo-orchitis. Consider pelvic/ obs & gynae pathology in the older child/ adolescent female if indicated.
Neuro – When conducting a neurological exam consider assessing for the signs of central nervous system infection which in the older child is similar to adults e.g. headache, drowsiness, confusion, nuchal rigidity or neck pain, photophobia, flu like symptoms seizures etc. However remember in babies and young children the symptoms may be much more non specific and you need to be wary of this e.g. irritability, fever in under 3 months, poor feeding, vomiting etc. Cranial nerves in young children and babies is limited however some components ca be tested e.g. observation of facial movements, pupils, clicking next to ears to see if child turns head to assess hearing, tracking of fun objects. This is the same with assessing tone and power, can the child grasp objects you hold up, is their good tone in the limbs.
Differential Diagnosis
The differential diagnosis of the child presenting with fever can be vast. common things are common and most children will be well with a self-limiting viral illness such as URTI or Otitis Media etc. However consideration needs to be made towards more serious diagnosis and NICE again provides us guidance towards the consideration of some conditions:
Image From NICE Guideline NG143
Conveyance Vs Non Conveyance Decision Making
After undertaking a comprehensive history and examination, considering differentials (especially the serious ones in the table above), hopefully you have landed on a likely differential of the reason for this child's fever. From here you should assess the child against the fever traffic light guidelines and decide if they have amber or red features.
Any red features should make you convey the child to hospital, if any life threatening presentations are identified then undertake appropriate management for this on route e.g. oxygen, fluid resuscitation, anticonvulsants, antibiotics etc as needed.
Any amber features should make you consider conveyance. Consider does this child need review by paediatrics especially if no focus has been found for the fever and likely this may be the outcome. Consideration to discharge can still be made as per NICE guidelines but there should be:
- robust safety netting with the parents and a plan for how to access further review
- Consideration to arranged follow up at a pre-set time e.g. GP later in the day. This should likely be agreed with the GP/ practitioner seeing the patient.
- These decisions can be discussed with a senior clinician e.g. paediatrician on call and shared decision making support used to create a safe plan.
o This could be parents conveying the child directly to the ward to be seen by the paediatrician on call
o Open access agreed with the paediatrician so if improvement doesn’t occur then the parents can self-present to the paediatrician.
o Follow up agreed with the patients GP practice at a set time frame
o Conveyance to ED agreed
Remember persistent tachycardia is concerning and warrants further investigation, however both an upset child and a child who is having a physiological response to a fever can induce a tachycardia. Consider calming the child, try for young children leaving a sats probe taped to the foot and putting a sock on top of this or applying 3 lead cardiac monitoring and then leaving the child alone with this still attached. This way they get used to its presence and forget about it before calming down giving a more accurate heart rate. Likewise if fever is the cause, consider giving antipyretics/ oral fluid challenge for the distressed child before finishing your assessment, take some time around 30-45 mins whilst documenting your history and examination in the notes and then review the child's physiology with a repeat set of observations, which is often mandatory in many trusts anyway but is always practice in assessing the unwell child. If there has been improvement, the child may now sit in the green category, if not and the tachycardia persists, strongly consider conveyance for further investigation because lets emphasise the point above PERSISTANT tachycardia is concerning and needs paediatrician review.
Only Green features with NO red/ amber flags. These patients can be safely discharged at scene with an appropriate plan. If you have identified the source of the fever e.g. otitis media, then provide self care advice on how to manage the specific condition in question. This information can be sourced commonly from the NICE clinical Knowledge Summaries (NICE CKS).
This should also include general measures for managing fever not covered in specific guidance such as advice on correct use of paracetamol/ ibuprofen, including dosing, max doses per 24 hours and why we are using it e.g. not to reduce the number on the thermometer but to manage the symptoms the child has e.g. pain, distress, irritability, clinginess, lethargy etc. This should then be complimented with appropriate safety netting advice. See our safe discharge podcast for more information on how to do this. Remember it needs to be specific, time framed and who to contact, ideally backed up with written discharge instructions.
Healthier together or the Handi Paediatrics app both have good useable worsening advice for parents that covers red flag symptoms they need to look out for and provides guidance on how to call for help and when. Remember to talk parents verbally through this and why we are asking them to look for these, giving a leaflet and not explaining it is nearly as bad as saying 999 any problems….. which if you have listened to our safe discharge podcast is not good practice or adequate protection for the practitioner.
Take away points:
The absolute number on the thermometer often doesnt matter, what matters is how the child is coping with the fever.
Exceptions to this rule are under 3 months where a temperature of 38+ and under 6 month where a temperature of 39/+ are red flags respectively.
Make sure you take the temp properly, consider if that probe was actually focused on the tympanic membrane.
We need to find the source of the fever so ensure that your history and examination is detailed enough for this.
Don’t start trying to assess kids straight away. If they arent obviously unwell, let them take time to get used to you and start taking a history from the parents.
Ask open questions , how is the child presenting with the fever and how are they coping.
Follow a structure… medical model or 3 minute tool kit are both good.
Dont be afraid to make the patient better. Trialling anti-pyretics and an oral fluid challenge can often help make your decision.
Make a plan: NICE traffic lights = all green probably suitable to consider discharge. Be an advocate for patients, if you dont think they need ED, share decision making with an expert and consider other options.
If discharging ensure we give detailed worsening advice, verbal and written to the parents. Ensure they are absolutely clear on when and how to recontact health care.
Remember, clinicians are responsible for their own practice. These podcasts are produced for informative purposes and should not be considered solely sufficient to adjust practice. We provide lots of learning resources, so don’t just take our word for it…navigate to these and reflect on this topic further. See "The Legal Bit" for more info.
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