Fever in Children

Year 1 Derby VTS Teaching

Aims and Objectives

What is fever?

Using 4 case studies we will consider:

How to differentiate between children with and without serious illness when there is no obvious cause in particular focusing on the history and examination

If and how an elevated temperature should be managed including strategies to manage parent’s fears.

Fever (1) Defined as1:

Rectal temperature above 38cOral temperature above 37.8cAxillary temperature above 37.2cTympanic temperature above 37.8

In 2-6 year old children diurnal variation of +/- 0.9c

Important physiological response during illness.

Fever (2)A viral or bacterial infection can reset the

thermoregulation centre in the hypothalamus producing an elevated temperature1.

Most cases of fever are due to benign viral illnesses, unfortunately serious infections such as meningitis and pneumonia may initially present with fever and the challenge is to identify those developing a serious infection1.

The most common bacterial infection in febrile children is a urinary tract infection1.

CasesDivide into 4 groups (Cases 1-4)Discuss the case and answer the questions

(15 minutes)Nominate two members of the group to

present the case and your group’s answers.

Case 1How to measure temperature?

NICE Guidelines

Age Method

<4 weeks 1. Axilla

4 weeks to 5 years 1. Axilla2. Tympanic

“Treating” fever

Most children are not uncomfortable until fever reaches 39.5-40C1

May consider not treating the fever1

Paracetamol and ibuprofen may be used1

Calculate the dose required carefully andensure parents know how to measure that dose. 1

Fever Phobia Studies have shown that a high percentage of

parents feel fever can have serious consequences. 1

It is underlying illness rather than fever itself which is responsible for most morbidity. 1

Vaccination

Before introduction of Hib and pneumococcal conjugate vaccines, the reported incidence of serious bacterial illness in a child with a fever who is <36 months ranged from 3-13%. 1

Since these vaccines were introduced liklihood of serious bacterial infection in children with a fever 3-36 months decreased to less than 2%. 1

Recent vaccination may be an aetiological factor for fever- can be expected 12-24hrs post DPT vaccination and can last 24-48hrs. 1

Case 2Increased risk of serious bacterial infection

because she has a significant temperature for her age and she is only 6 weeks old. 1

Referral to secondary care would be appropriate.

Introduction to traffic lights handouts(NICE guidelines)

Traffic lights

When to admit to hospital? Any RED features Admit

Amber features Use clinical judgement but it may be appropriate

to monitor the situation in the community

Only Green features Usually safe for management at

home

Case 3How does your practice triage telephone calls

from parents who phone about a child with a fever?

Often a face to face clinical assessment will be necessary to make a safe clinical judgement about fever in young children so some practices have a policy of seeing all under 5’s in the emergency surgery.

Role Play

Case 3Moderate risk categoryLiklihood of bacteraemia is low as Ryan is

up to date with immunisationsMay have an occult pneumoniaUTI is uncommon in a boy of this age who

has no symptoms1

Case 4Judging a temperature by touch is

unreliableOral or tympanic temperature is indicated

in a child of David’s ageHow might you differentiate between

isolated delirium and a globally impaired CNS function?

DeliriumUncommon symptom in children1

Fever alone is a common reason when it does occur1

Usually quick recovery (minutes to hours) 1

Normal neurological examination1

Warning: Delirious behaviour can also be a symptom of acute encephalopathy1

Take Home PointsThe younger the age, the greater the risk of a

serious bacterial infection underlying the feverUse NICE traffic light system to guide

management

References1.Fever in Children, Scotland PBSG Learning

Programme. Accessed at www.nes.scot.nhs.uk/medicine/gpcpd/pbsg/

2.NICE guideline 47. Feverish Illness in Children: Assessment and initial management of children younger than 5 years.

Any Questions?