The Pyrexial Child
in primary care setting
Dr Hassan DawoodSHO GP
Structure of the Presentation
How to measure T? Causes of pyrexia in childhood Assessment (Traffic Light System) Signs & symptoms Specific diseases
Management Antipyretics Management by the paediatric specialist
How To Measure T?NICE Guidelines ( < 5 yrs )
DON'T : ( ORAL / RECTAL ) ROUTE
- < 4 wks: electronic thermometer in the axilla - 4 wks - 5 yrs: • electronic thermometer in the axilla • chemical dot thermometer in the axilla • infra-red tympanic thermometer
- Parental perception
Causes Of Pyrexia In Children
I - C - C - R - Ex - ++
• Infections • Convultions * <===>• CA• Rheumatoid• External factors• Over dressing
Assessment
Level of Risk ( Traffic Light System)
• ABCD inc CR ( + T ) ? DEFG
• Hx / Ex:
o ? Abroado ? Source o ? Specific signs & Symptoms
• ? Infection screen
Colour
Activity
Respiratory
Hydration
Other
Herpes Simplex Encephalitis
Meningitis, Meningococcal Dis
Pneumonia
Kawasaki disease
UTI
Septic arthritis/osteomyelitis
• Neck stiffness • Bulging fontanelle • level of consciousness
Non-blanching with 1 or more: • an ill-looking child • larger than 2 mm in diameter • CRT ≥3 seconds • neck stiffness
Fever >5 days & 4 of the following: • bilateral conjunctival inj• change in URT mucous membranes (eg, injected pharynx, dry cracked lips or strawberry tongue) • change in the periph extremities (eg,oedema, erythema or desquamation) • polymorphous rash • cervical lymphadenopathy
• Focal neur signs/ fits• level of consciousness
• Tachypnoea 0–5 m – RR > 60 b/m 6–12 m – RR > 50 b/m > 12 m – RR > 40 b/m• Crackles, Nasal flaring, Chest indrawing, Cyanosis • Sats ≤95%
(> 3 months)• Poor feeding, Vomiting, Lethargy, Irritability, Abdo pain • Frequency or dysuria • Offensive urine or haematuria
• Swelling of a limb or joint
• Not using an extremity • Non-weight bearing
+ FEVER
ManagementGREEN ( LOW RISK ) Manage at home with advice: • Antipyretic• Hydrate ++ (if breastfeeding to cont as normal)• Off school/ nursery • When to seek help:
o Signs of dehydration : fontanelle, eyes, tears, mouth, overall
appearenceo Non-blanching rash (glass test)o Fitso Parents ditress/ concerno Fever >5 days
Management
AMBER ( INTERMEDIATE RISK )
Provide parents / carers with a safety net:• Verbal ± written info re warning symp• How to access further healthcare / Liaise on with out
of hrs• ? F/U
RED ( HIGH RISK )
Ref urgently to Paeds
Further Invx & Management
● Test fo UTI ● If pneumonia is suspected but the child has not been referred to hospital, do not routinely perform CXR
● Do not prescribe oral ABx to a child with fever without apparent source
● If meningococcal disease is suspected, give parenteral ABx ASAP (benzylpenicillin or a third-generation cephalosporin)
Antipyretics● Tepid sponging is not recommended. ● Do not over or under dress a child with fever.
● Consider either paracetamol or ibuprofen as an option if the child appears distressed or is unwell. ● Do not administer paracetamol and ibuprofen at the same time, but consider using the alternative agent if the child does not respond to the first drug. ● Do not routinely give antipyretics with the sole aim of reducing body temperature. ● Do not use antipyretics with the sole aim of preventing febrile convulsions.
Management by the paediatric specialist
● Children with fever without apparent source presenting to paediatric specialists with one or more ‘red’ features should have the following investigations performed: – FBC– BC – CRP – urine testing for UTI.
● The following investigations should also be considered in children with ‘red’ features, as guided by the clinical assessment: – LP in children of all ages (if not contraindicated) – CXR irrespective of body temperature & WCC– U+Es & BG
Structure of the Presentation
How to measure T? Causes of pyrexia in childhood Assessment (Traffic Light System) Specific signs & symptoms specific diseases
Management Antipyretics Management by the paediatric specialist