Fever Pathway for Children Younger than 5 years K e n t, S

December
u rr
2016
ey & Susse
x Version
South East Clinical Networks
Clinical Assessment / Management Tool Children and Young People

Management - Primary Care and Community Settings Think

Sepsis
Patient presents with or has a history of fever (see definition and initial Do the symptoms and/or signs suggest an • Refer immediately to emergency care by 999
assessment guidance) [ see Table 3 overleaf ] immediately life threatening (high risk) illness? Yes • Alert Paediatric Emergency Service*
(Consider additional vulnerability to sepsis) [ see Table 4 overleaf ] or any risk of neutropenic sepsis? • Stay with child whilst waiting and prepare documentation
and AVPU [see Table 5 overleaf]

No
Table 1
Clinical
Findings Green - low risk Amber - intermediate risk Red - high risk

Advanced Life Support Group Edited by Martin Samuels; Susan Wieteska

Heart Rate
GMC Best Practice recommendation http://bit.ly/1DPXl2b

100 - 150
110 - 160

95 - 140
Advanced Paediatric Life Support The Practical Approach Fifth Edition
Colour • Normal colour of skin, lips and tongue • Pallor reported by parent/carer • Pale/mottled/ashen/blue

[bpm]
Activity • Responds normally to social cues • Reduced response to social cues • No response to social cues
• Content / smiles • Wakes only with prolonged stimulation • Unable to rouse or if roused does not stay awake
• Stays awake or awakens quickly • Decreased activity • Weak, high pitched or continuous cry
• Strong normal cry / not crying • No smile • Appears ill to a healthcare professional
Respiratory • None of the amber or red symptoms • Nasal flaring • Grunting

Rate at rest: [b/min]

Rate or signs • Tachypnoea: - Age < 1 yr RR 50 - 59 breaths/min • Tachypnoea: - Age < 1 yr RR ≥ 60 breaths/min
Measured at rest for - Age 1 - 2 yr RR 40 - 49 breaths/min - Age 1 - 2 yr RR ≥ 50 breaths/min

Respiratory
30 seconds
- Age 3 - 4 yr RR 30 - 39 breaths/min - Age 3 - 4 yr RR ≥ 40 breaths/min

Normal Paediatric Values:

30 - 40
25 - 35
25 - 30
• Oxygen saturation ≤ 95% in air
• Crackles

999
Record your findings.

Circulation • Normal skin and eyes • Tachypnoea: - Age < 1 yr HR 150 - 159 beats/min • Sustained Tachycardia - Age < 1 yr HR ≥ 160 beats/min

Wiley-Blackwell / 2011 BMJ Books.

and Hydration • Moist mucous membranes - Age 1 - 2 yr HR 140 - 149 beats/min - Age 1 - 2 yr HR ≥ 150 beats/min
• Normal feeding - Tolerating 75% of fluid - Age 3 - 4 yr HR 130 - 139 beats/min - Age 3 - 4 yr HR ≥ 140 beats/min
• Dry mucous membranes • Reduced urine output / nappies • Hypotension • <50% fluid intake over 2 - 3 feeds /
• Poor feeding in infants significantly drier than normal • CRT > 4 seconds 12 hours or appears dehydrated
• 50 - 75% fluid intake • Cool extremities • Reduced skin turgor • no urine output/dry nappies

3 & 4 years
over 3 - 4 feeds • CRT ≥ 3 seconds for > 18 hours

1-2 years
< 1 year
(APLS†)
Other • None of the amber or red symptoms • Age 3-6 months temp ≥39°C (102.2°F) • Age 0-3 months, temp ≥ 38°C (100.4°F)
or signs • Fever for ≥ 5 days • A new lump ≥ 2 cm • Bulging fontanelle • Neck stiffness
• Rigors • Focal neurological signs

Table 2
• Swelling of a limb or joint • Status epilepticus
• Non-weight bearing / • Septicaemia maybe associated • Focal seizures • Bile-stained vomiting
not using an extremity with low temperature < 36°C • Non-blanching rash

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Provide appropriate and clear guidance to the parent and symptoms and changes and signpost as to
/ carer and refer them to the patient advice sheet. where to go should things change
Confirm they are comfortable with the decisions /
advice given and then think “Safeguarding” before • Arrange any required follow up or review
sending home. Hospital Emergency
• Send any relevant documentation to the
provider of follow up or review Department / Paediatric Unit
*Please see overleaf for telephone numbers

This guidance is written in This document was arrived at after careful consideration of the evidence available including but not exclusively NICE, SIGN, EBM data and NHS evidence, as applicable. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement.
The guidance does not, however, override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient in consultation with the patient and / or carer.
the following context:
 Supporting Information
South East Clinical Networks
2016
December
Children and Young People
n
e y & S u s sex Versio
Ken t, S u rr

What is a fever (Definition)? Where can I learn more about paediatric

NICE CG160 Guidance states: In children, a temperature of over 37.5°C is a fever. Reported parental
perception of a fever should be considered valid and taken seriously by healthcare professionals.
Assessment of a child with sepsis
- When a child presents with signs or symptoms of infection:
assessment?
We also recommend signing up to the online and interactive learning
tool Spotting the Sick Child. It is free of charge. It was commissioned
by the Department of Health to support health professionals in the
assessment of the acutely sick child. It is also CPD certified.

First Draft Version: May 2011 Subsequent Versions have been published in Nov 2013, Jan 2015
Table 3 - Initial Assessment Guidance Table 4 www.spottingthesickchild.com
Child presents with signs and/or symptoms of infection Consider additional vulnerability to sepsis:
• Think sepsis, even if they do not have a high temperature • the very young (<1yr) *GP / Clinician Priority Phonelines / Contact Numbers at
Local Hospitals

and May 2015. Date of this Refreshed Version: Dec 2016 Review Date: Dec 2018.
• non-immunised
• Be aware that children with sepsis may have non-specific,
non-localising presentations • recent (<6 weeks) trauma or surgery or
invasive procedure Surrey and Sussex Area Hospitals Western Sussex Hospitals NHS Trust St
NICE clinical guideline 160 (May 2013) And based on: Sepsis: recognition, diagnosis and early management Guidelines NG51 https://www.nice.org.uk/guidance/ng51 July 2016.

• Pay particular attention to concerns expressed by the • Impaired immunity due to illness or drugs
child and family/carer Ashford and St Peter’s Hospital NHS Richards Hospital, Chichester 01243 536180/1
• Indwelling lines/catheters, any breach of skin Worthing Hospital 01903 285060
Based on Feverish illness in children Assessment and initial management in children younger than 5 years 2007 NICE clinical guideline 47 and with consideration to 2013

• Take particular care in the assessment of children, who integrity e.g. any cuts, burns, blisters or skin Foundation Trust, Chertsey 01932 872000
might have sepsis, who are unable, or their parent/carer is infections. Brighton and Sussex University Hospitals Kent and Medway Area Hospitals
unable, to give a good history If at risk of neutropenic sepsis - refer to
secondary care NHS Trust Royal Alexandra Hospital, Brighton Dartford and Gravesham NHS Trust
01273 523230 Darent Valley Hospital / Queen Marys Hospital
The assessment of a child with fever should include measurement of Temperature, Heart Rate (HR), East Sussex Healthcare NHS Trust Sidcup / Erith and District Hospital
Respiratory Rate (RR) at rest and Oxygen saturations & Blood Pressure where available. Conquest Hospital, Hastings 01424 755255 01322 428100 Bleep 316 (same number applies
Eastbourne District General Hospital to both hospital sites)
Table 5 Level of Consciousness 01323 417400 East Kent Hospitals NHS Trust
Assessment “AVPU” Frimley Park Hospital NHS Foundation Trust, Queen Elizabeth The Queen Mother Hospital,
Status Behaviour Assessment Camberley 01276 604604 Bleep 100 Margate / William Harvey Hospital, Ashford
The AVPU scale is a system for measuring 01227 783190 (same number applies to both
and recording a patient’s responsiveness in Royal Surrey County Hospital NHS
Child is active and responds Foundation Trust, Guildford 01483 571122 hospital sites)

A
order to indicate their level of consciousness.
ALERT

appropriately to clinician and
other external stimuli.
[GCS equivalent score 15]
It is a simplification of the Glasgow Coma
Scale, using three measures to assess a
patient’s response: eyes, voice, and motor
skills. The AVPU scale should be assessed
Surrey and Sussex Healthcare NHS Trust Maidstone and Tonbridge Wells NHS Trust
01622 723011
East Surrey Hospital, Redhill 01737 231807
Medway Maritime Hospital, Gillingham
01634 825000

V
using these three identifiable traits, looking
VOICE

Responds only when his or her
name is called by clinician.
for the best response for each. It has four
possible outcomes for recording and the
clinician should always work from best (A)
to worst (U) to avoid unnecessary tests on
patients who are clearly conscious. On the
Dear Colleague,
We are delighted to present you with this Fever Pathway Clinical Assessment / Management Tool for
Children Younger than 5 years – in Primary Care and Community Settings.
The local clinical groups who played such an important role in creating these tools, starting from
2010, have included representatives from acute, community and primary care as well as parents,

P
Responds only when painful education and social care. In particular we would also like to thank Wessex SCN and Paediatrics
PAIN

stimuli is received such as
pinching the nail bed.
UNRESPONSIVE
other hand, it should not be used for long-term
follow up of neurological status.
Glossary of Terms and Abbreviations
CPD Continuous Professional Development
and Emergency Medicine colleagues for their support in finalising these versions for circulation.
To feedback or for further information including how to obtain more copies (Please Quote Ref: F2) of
this document we have one mailbox for these queries on behalf of the South East
Clinical Networks area (Kent, Surrey and Sussex).

U
HR Heart Rate Please email: CWSCCG.cypSECpathways@nhs.net
No response at all.
[GCS equivalent score 3] CRT Capillary Refill Time Yours sincerely
RR Respiratory Rate
ED Hospital Emergency Department The Network