Paediatrics: Fever: examination and assessment

Fever: examination and assessment

When assessing a child with a fever a thorough history and examination are required. In the UK the National Institute for Health and Clinical Excellence (NICE) has provided a clinical guideline on ‘Feverish illness in children’ (see M www.nice.org.uk/CG047 for updates). The following sec-tion is adapted from this guideline. The key priorities are:

·  History: consider very seriously parent’s concerns and perception of a fever in their child. Check for ill contacts, immunization history.

·  Measurements: make sure that temperature, heart rate, respiratory rate, and capillary refill time are measured as this will determine the order of your priorities.

·  Signs and symptoms: assess the child for the presence or absence of symptoms and signs indicating serious illness.

Boxes 19.2–19.4 summarize the NICE guidelines on features of an illness that are at low-risk of indicating serious illness (green), to intermediate-risk (amber), to high-risk (red).

Box 19.2 Features (‘green’) indicating low risk of serious illness

·  Colour: normal colour of skin, lips, and tongue

·  Activity:

·  responds normally

·  is content and smiles

·  stays awake or awakens quickly if roused

·  strong normal cry

·  Breathing: normal

·  Hydration: normal

·  Other:

·  generally normal

no fever at time of examination

Box 19.3 Features (‘amber’) indicating intermediate risk of serious illness

·Colour: pallor reported by parent or carer

·Activity:

·  not responding normally and decreased activity

·  prolonged stimulation required to awaken child

·Breathing:

·  nasal flaring

·  tachypnoea (>50breaths/min in 6–12-mth-olds; >40breaths/min in >1yr-old)

·  desaturation in air (≤95% in air)

·  chest crackles

·Hydration:

·  dry mucous membranes

·  poor feeding

·  reduced urine output

·  capillary refill time >3s

·Other:

·  fever  5 days

·  swelling of limb or joint

·  non-weight bearing or not using an extremity

·  a new lump >2cm

Box 19.4 Features (‘red’) indicating high risk of serious illness

·Colour: pale, mottled, ashen, or blue

·Activity:

·  unresponsive, appears ill, and barely rousable

·  weak high-pitched or continuous cry

·Breathing: grunting, severe distress

·Hydration: reduced skin turgor

·Other:

•   non-blanching rash

•   fever at time of examination

•   bulging fontanelle

•   neck stiffness

•   seizures or focal neurology

•   bile-stained vomiting