General / Acute

Question 1

What are normal values for HR?

Answer 1

0-1: 110-160
1-2: 100-150
2-5: 95-140
6-12: 80-120
12-18: 60-100

Question 2

What are normal values for systolic BP?

Answer 2

0-1: 80-90
1-2: 70-95
2-5: 85-100
6-12: 90-110
12-18: 90-120

Question 3

What are normal values for RR?

Answer 3

0-1: 30-40

2-5: 25-30
6-12: 20-25
12-18: 15-20

Question 4

What tool is used to assess children with a fever?

Answer 4

NICE traffic light system for <5 years

All green - low risk
Any in amber (but no red) - intermediate risk
Any in red - high risk

Question 5

What signs and symptoms put a feverish child <5 in the low risk category?

Answer 5

Normal colour (skin, lips tongue)

Responds normally to social cues

Content/smiles

Stays awake or awakens quickly

Strong normal cry or not crying

Normal skin and eyes

Moist mucous membranes

Question 6

What signs and symptoms put a feverish child <5 in the low risk category?

Answer 6

Normal colour (skin, lips tongue)

Responds normally to social cues

Content/smiles

Stays awake or awakens quickly

Strong normal cry or not crying

Normal skin and eyes

Moist mucous membranes

Question 7

What signs and symptoms put a feverish child <5 in the intermediate risk category?

Answer 7

Colour: PALLOR of skin/lips/tongue reported by parent/carer

Activity: NOT responding normally to social cues, NO smile, wakes only with prolonged stimulation, decreased activity

Resp: NASAL FLARING, TACHYPNOEA (>50 if 6-12 months, >40 if >12 months), SATS <95%, CRACKLES

Circulation: DRY mucous membranes, POOR feeding (infant), REDUCED URINE output, CAPILLARY REFILL >3s, TACHYCARDIA (>160 if <1, >150 if 1-2, >140 if 2-5)

Other: 3-6 months + temp 39, fever lasting 5 days, rigors, swelling of limb or joint, non-weight bearing limb / not using extremity

Question 8

What signs and symptoms put a feverish child <5 in the HIGH risk category?

Answer 8

Colour: PALE / MOTTLED / ashen / BLUE skin, lips or tongue

Activity: No response to social cues, appearing ill to healthcare professional, does not wake or if roused DOES NOT STAY AWAKE, WEAK, HIGH-PITCHED or CONTINUOUS cry

Resp: GRUNTING, tachypnoea (RR >60), moderate or severe chest INDRAWING

Circulation: Reduced SKIN TURGOR

Other: <3 months + temp 38, non-blanching rash, bulging fontanelle, neck stiffness, status epilepticus, focal neurological signs, focal seizures

Question 9

Based on age, which temperatures are considered intermediate or high risk?

Answer 9

<3 months + temp 38 - high risk

3-6 months + temp 39 - intermediate risk

Question 10

How should a <5y with fever be assessed (investigations etc)?

Answer 10

All require temp, HR, RR and cap refill. If HR or capillary refill abnormal, measure BP.

If >6 months do not use of height of body temperature alone to identify those with serious illness. If given antipyretics do not rely on decrease/lack of decrease in temp to differentiate seriousness level. Do not use duration of fever to predict likelihood of serious illness, however, if >5 days should be assessed for Kawasaki disease.

Assess for dehydration (capillary refill, skin turgor, abnormal respiratory pattern, weak pulse, cool extremities).

Assess for signs and symptoms of specific illness (meningococcal disease, bacterial meningitis, herpes simplex encephalitis, pneumonia, UTI, septic arthritis / osteomyelitis, Kawasaki disease).

Enquire about travel + consider imported infections

Test urine but signs suggesting pneumonia do not require CXR if not admitted.

Question 11

When assessing child <5 with fever, what would suggest meningococcal disease?

Answer 11

Non-blanching rash, particularly with 1 or more of the following:

ill looking child, lesions >2mm diameter (purpura), CRT >3s, neck stiffness

Question 12

When assessing child <5 with fever, what would suggest bacterial meningitis?

Answer 12

neck stiffness, bulging fontanelle, decreased consciousness, convulsive status epilepticus

Question 13

When assessing child <5 with fever, what would suggest herpes simplex encephalitis?

Answer 13

focal neurological signs, focal seizures, decreased level of consciousness

Question 14

When assessing child <5 with fever, what would suggest pneumonia?

Answer 14

tachypnoea (>60 if 0-5m, >50 if 6-12m, >40 if >12m)

crackles, nasal flaring, chest indrawing, cyanosis, sats <95%

Question 15

When assessing child <5 with fever, what would suggest UTI?

Answer 15

Vomiting
Poor feeding
Lethargy
Irritability
Abdo pain or tenderness
Urinary frequency or dysuria

Question 16

When assessing child <5 with fever, what would suggest septic arthritis?

Answer 16

swelling of limb or joint
not using an extremity
non-weight bearing

Question 17

When assessing child <5 with fever, what would suggest Kawasaki disease?

Answer 17

fever >5 days and at least 4 of the following:

bilateral conjunctival injection
change in mucous membranes
change in extremities
polymorphous rash
cervical lymphadenopathy

Question 18

How should a <3m with fever be assessed (investigations etc)?

Answer 18

Temp, HR and RR recorded

FBC, culture, CRP, urinalysis, CXR only if respiratory signs, stool culture only if diarrhoea present

LP if <1 month, 1-3 months and appearing unwell or 1-3 months with WBC <5 or >15

Parenteral antibiotics: all <1m, all 1-3m appearing unwell or with WBC <5 or >15

Question 19

How should a child over 3 months with fever in the ‘high risk’ zone be assessed (investigations etc)?

Answer 19

FBC, blood culture, CRP, urine testing, U&Es, blood gas

LP if not contraindicated
CXR (irrespective of temp and WBC)

Question 20

How should a child over 3 months with fever in the ‘intermediate risk’ zone be assessed (investigations etc)?

Answer 20

Urine sample, FBC, CRP, cultures, LP if <1 year, CXR if temp 39 and WBC >20

Question 21

How should a child over 3 months with fever in the ‘low risk’ zone be assessed (investigations etc)?

Answer 21

Urine sample
Assessed for symptoms / signs of pneumonia

Do not routinely do bloods / CXR

Question 22

When should antipyretics be given for children with fever?

Answer 22

Only if distressed - consider paracetamol OR ibuprofen (not simultaneously), only for as long as appears distressed, consider changing to the other agent if distress not alleviated

Question 23

If child with fever is being cared for at home, what advise should be given?

Answer 23

Regular fluids (breast milk most appropriate if breastfed)

Advice on detecting dehydration: sunken fontanelle, dry mouth, sunken eyes, no tears, poor overall appearance

Identifying non-blanching rash

Check child during night

Keep away from nursery / school while fever persists

Seek further advise if: seizure, non-blanching rash, less well than when they sought advice, LONGER THAN 5 DAYS, carer distressed or concerned unable to look after child