Feverish_Illness_in_Children_Flashcards
What is the ‘traffic light’ system for risk stratification of children under the age of 5 years with a fever?
Introduced by the 2007 NICE guidelines and modified in a 2013 update, it classifies children into Green (low risk), Amber (intermediate risk), and Red (high risk) categories based on symptoms and signs.
What should be recorded in all febrile children during assessment?
Temperature, heart rate, respiratory rate, capillary refill time, and signs of dehydration (reduced skin turgor, cool extremities, etc.).
How should temperature be measured in febrile children?
With an electronic thermometer in the axilla if the child is < 4 weeks or with an electronic/chemical dot thermometer in the axilla or an infra-red tympanic thermometer.
What are the Green (low risk) criteria for febrile children?
Normal color, responds normally to social cues, content/smiles, stays awake or awakens quickly, strong normal cry/not crying.
What are the Amber (intermediate risk) criteria for febrile children?
Pallor reported by parent/carer, not responding normally to social cues, no smile, wakes only with prolonged stimulation, decreased activity, nasal flaring, tachypnoea, oxygen saturation <=95% in air, crackles in the chest, tachycardia, capillary refill time >=3 seconds, dry mucous membranes, poor feeding in infants, reduced urine output, age 3-6 months with temperature >=39ºC, fever for >=5 days, rigors, swelling of a limb or joint, non-weight bearing limb/not using an extremity.
What are the Red (high risk) criteria for febrile children?
Pale/mottled/ashen/blue, no response to social cues, appears ill to a healthcare professional, does not wake or if roused does not stay awake, weak/high-pitched/continuous cry, grunting, tachypnoea >60 breaths/minute, moderate or severe chest indrawing, reduced skin turgor, age <3 months with temperature >=38°C, non-blanching rash, bulging fontanelle, neck stiffness, status epilepticus, focal neurological signs, focal seizures.
What is the management for children classified as Green (low risk)?
Child can be managed at home with appropriate care advice, including when to seek further help.
What is the management for children classified as Amber (intermediate risk)?
Provide parents with a safety net or refer to a paediatric specialist for further assessment. A safety net includes verbal or written information on warning symptoms, how further healthcare can be accessed, a follow-up appointment, and liaison with other healthcare professionals for further follow-up.
What is the management for children classified as Red (high risk)?
Refer child urgently to a paediatric specialist.
What is a key point regarding the prescription of oral antibiotics for children with fever without an apparent source?
Oral antibiotics should not be prescribed to children with fever without apparent source.
What should be done if pneumonia is suspected in a febrile child who is not going to be referred to hospital?
A chest x-ray does not need to be routinely performed.
summarise fever in children
Feverish illness in children
The 2007 NICE Feverish illness in children guidelines introduced a ‘traffic light’ system for risk stratification of children under the age of 5 years presenting with a fever. These guidelines were later modified in a 2013 update.
It should be noted that these guidelines only apply ‘until a clinical diagnosis of the underlying condition has been made’. A link to the guidelines is provided but some key points are listed below.
Assessment
The following should be recorded in all febrile children:
temperature
heart rate
respiratory rate
capillary refill time
Signs of dehydration (reduced skin turgor, cool extremities etc) should also be looked for
Measuring temperature should be done with an electronic thermometer in the axilla if the child is < 4 weeks or with an electronic/chemical dot thermometer in the axilla or an infra-red tympanic thermometer.
Risk stratification
Please see the link for the complete table, below is a modified version
Green - low risk Amber - intermediate risk Red - high risk
Colour * Normal colour * Pallor reported by parent/carer * Pale/mottled/ashen/blue
Activity * 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 * No response to social cues
* Appears ill to a healthcare professional
* Does not wake or if roused does not stay awake
* Weak, high-pitched or continuous cry
Respiratory * Nasal flaring
* Tachypnoea: respiratory rate
>50 breaths/minute, age 6-12 months;
>40 breaths/minute, age >12 months
* Oxygen saturation <=95% in air
* Crackles in the chest * Grunting
* Tachypnoea: respiratory rate >60 breaths/minute
* Moderate or severe chest indrawing
Circulation and hydration * Normal skin and eyes
* Moist mucous membranes * Tachycardia:
>160 beats/minute, age <12 months
>150 beats/minute, age 12-24 months
>140 beats/minute, age 2-5 years
* Capillary refill time >=3 seconds
* Dry mucous membranes
* Poor feeding in infants
* Reduced urine output * Reduced skin turgor
Other No amber or red signs * Age 3-6 months, temperature >=39ºC
* Fever for >=5 days
* Rigors
* Swelling of a limb or joint
* Non-weight bearing limb/not using an extremity * Age <3 months, temperature >=38°C
* Non-blanching rash
* Bulging fontanelle
* Neck stiffness
* Status epilepticus
* Focal neurological signs
* Focal seizures
Management
If green:
Child can be managed at home with appropriate care advice, including when to seek further help
If amber:
provide parents with a safety net or refer to a paediatric specialist for further assessment
a safety net includes verbal or written information on warning symptoms and how further healthcare can be accessed, a follow-up appointment, liaison with other healthcare professionals, e.g. out-of-hours providers, for further follow-up
If red:
refer child urgently to a paediatric specialist
Other key points include
oral antibiotics should not be prescribed to children with fever without apparent source
if a pneumonia is suspected but the child is not going to be referred to hospital then a chest x-ray does not need to be routinely performed
A 3-year-old child is brought to the emergency department. She has been feverish for the last two days. She has also been feeling tired and irritable, with decreased appetite. She complained of a headache earlier today.
On examination, she wakes only with prolonged stimulation. Her temperature is 39.2 ºC, heart rate 110/min, respiratory rate 66/min, and blood pressure 100/60 mmHg. Her throat is mildly erythematous. Her abdomen is soft and non-tender, and no rashes are observed. Her parents are really worried.
What indicates a red flag according to the NICE paediatric traffic light system?
Her activity levels
Her heart rate
Her respiratory rate
Her temperature
Parental concern
Her respiratory rate
A respiratory rate of >60 per minute (at any age) is a red flag according to the NICE paediatric traffic light system
The correct answer is her respiratory rate. This child presents generally unwell with unspecific symptoms, which is common in paediatric. She has complained of a headache. Given the usually unspecific presentations in children, NICE has instituted a risk-stratification tool to identify which children are at risk of serious illness. Following this tool, a respiratory rate greater than 60 per minute at any age is a red flag, making this option correct, as her respiratory rate is 66 per minute.
Her activity levels is incorrect. Currently, she wakes only with prolonged stimulation. This is an amber feature, indicating intermediate risk. Under this category, not waking or if roused does not stay awake is a red flag.
Her heart rate is incorrect. Her heart rate is 110/min, this is not a worrying feature. Under this category, her heart rate exceeding 140 beats/minute would be a red flag given her age.
Her temperature is incorrect. Her temperature is 39.2 ºC, this is not a worrying feature. This would be worrying if she was less than three months old, which she isn’t, making this option incorrect.
Parental concern is incorrect. Parental concern is regarded as an amber flag. Concern expressed by a healthcare professional, on the other side, it’s a red flag.
A 2 month old baby is brought in to hospital with a fever. The child is pyrexial, with nil respiratory signs on examination and no diarrhoea. Which of the following would be part of your initial investigations?
ESR
Blood culture
Chest radiograph
Stool culture
Liver function tests
Blood culture
Perform the following investigations in infants younger than 3 months with fever:
Full blood count
Blood culture
C-reactive protein
Urine testing for urinary tract infection
Chest radiograph only if respiratory signs are present
Stool culture, if diarrhoea is present
Source: NICE guidelines (https:www.nice.org.uk/guidance/cg160/chapter/1-recommendations).
