Clinical Practice Guidelines : Febrile child 8/5/23, 22:39

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Febrile child

See also
Fever and suspected or confirmed neutropenia
(https://www.rch.org.au/clinicalguide/guideline_index/Fever_and_suspected_or_confirmed_neutropenia/)
Fever in the recently returned traveller (https://www.rch.org.au/clinicalguide/guideline_index/Fever_in_the_recently_returned_traveller/)
Kawasaki disease (https://www.rch.org.au/clinicalguide/guideline_index/Kawasaki_Disease_Guideline/)
Petechiae and Purpura (https://www.rch.org.au/clinicalguide/guideline_index/Fever_and_Petechiae_Purpura/)
Sepsis – assessment and management (https://www.rch.org.au/clinicalguide/guideline_index/SEPSIS_assessment_and_management/)
Local antimicrobial guidelines (https://www.rch.org.au/clinicalguide/guideline_index/Local_Antimicrobial_Guidelines/)

Key points
1. Febrile neonates ≤28 days of corrected age require investigations (FBE, CRP, blood, urine and CSF cultures ± CXR) and empiric
IV antibiotic therapy
2. In Febrile infants >28 days of corrected age and <3 months, have a low threshold for investigation and treatment based on clinical
appearance and presence (or absence) of a clinically obvious focus
3. In infants <3 months of age, hypothermia or temperature instability can be signs of serious bacterial infection (or other serious
illness)
4. The severity of illness cannot be predicted by the degree of fever, its rapidity of onset, its response to antipyretics or the presence
of febrile seizures; the appearance of the child is the most useful indicator
(https://www.rch.org.au/clinicalguide/guideline_index/Febrile_seizure/)

Background
Definition of fever: body temperature >38.0º Celsius
Where possible, use the same body site and the same type of thermometer when measuring temperatures (see Additional notes
below)
The most common causes of fever in children are viral infections, however serious bacterial infections (SBIs) need to be
considered
The most common SBIs found in children without a focus are urinary tract infections
Other SBIs to consider include: pneumonia

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Clinical Practice Guidelines : Febrile child 8/5/23, 22:39

(https://www.rch.org.au/clinicalguide/guideline_index/Community_acquired_pneumonia/), meningitis
(https://www.rch.org.au/clinicalguide/guideline_index/Meningitis_encephalitis/), bone and joint infections
(https://www.rch.org.au/clinicalguide/guideline_index/Osteomyelitis_and_septic_arthritis/), skin
(https://www.rch.org.au/clinicalguide/guideline_index/Cellulitis_and_other_bacterial_skin_infections/) and soft tissue infections,
mastoiditis, bacteraemia, sepsis (https://www.rch.org.au/clinicalguide/guideline_index/SEPSIS_assessment_and_management/)
Since the introduction of the pneumococcal vaccine, the rate of occult bacteraemia has fallen to <1% in healthy, immunised
children
Children with fever for ≥5 days should be assessed for Kawasaki disease
(https://www.rch.org.au/clinicalguide/guideline_index/Kawasaki_Disease_Guideline/) or PIMS-TS
(https://www.rch.org.au/clinicalguide/guideline_index/COVID-19/) if there is a history of COVID-19 infection
Other uncommon causes of prolonged fever in children include inflammatory, immune-mediated and neoplastic conditions;
specialist input may be required

Assessment
History
Localising symptoms eg cough, headache, photophobia, diarrhoea, vomiting, abdominal pain, musculoskeletal pain, rash
Travel
Sick contacts
Immunisation: children <6 months age or with incomplete immunisation
Medication: prior treatment with antibiotics may mask signs of a bacterial infection
High risk: prematurity, immunosuppression/oncological conditions (see Fever and suspected or confirmed neutropenia
(https://www.rch.org.au/clinicalguide/guideline_index/Fever_and_suspected_or_confirmed_neutropenia/)), central line in situ,
chronic lung disease, congenital heart disease, previous invasive bacterial infections, children of Aboriginal, Torres Strait Islander,
Pacific Islander or Maori origin, multiple health service presentations

Notes
Teething does not cause fever
Post vaccination fever is common, with a typical onset within 24 hours of immunisation and duration up to 2-3 days; however, in an
unwell child, fever should not be attributed to vaccination alone

Examination
Certain aspects of the child's behaviour and appearance provide the best indication of whether they are at high risk of SBI

Features suggestive of an unwell child

Pallor (including parent/carer report)

Colour Mottled
Blue/cyanosed

Activity Lethargy or decreased activity

Not responding normally to social cues
Does not wake or only with prolonged stimulation, or if roused, does not stay awake
Weak, high-pitched or continuous cry

Respiratory Grunting
Tachypnoea
Increased work of breathing

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Clinical Practice Guidelines : Febrile child 8/5/23, 22:39

Hypoxia

Circulation and Hydration Poor feeding

Dry mucous membranes
Persistent tachycardia
Central capillary refill time ≥3 seconds
Reduced skin turgor
Reduced urine output

Neurological Bulging fontanelle

Excessive irritability
Neck stiffness
Focal neurological signs
Focal, complex or prolonged seizures

Other Non-blanching rash

Fever for ≥5 days
Swelling of a limb or joint
Non-weight bearing/not using an extremity

Adapted from: Feverish illness in children NICE guideline 2019 (https://www.nice.org.uk/guidance/ng143)

The child should be examined for a clinical focus of infection

Remove clothing as required to complete a full examination, looking for subtle signs

Management
Any febrile child who appears seriously unwell should be managed as suspected sepsis (see Sepsis
(https://www.rch.org.au/clinicalguide/guideline_index/SEPSIS_assessment_and_management/)), irrespective of the degree of
fever
Do not accept apparent otitis media or upper respiratory symptoms as the source of infection in young infants or unwell
children. These children still require assessment for possible SBI
If the child is stable, it is preferable to complete investigations looking for an infective focus before commencing antibiotics
In children from high risk groups, have a lower threshold for investigations
UTI is the most common SBI, if there is no clinically obvious focus for fever, urine collection and testing should be performed
When blood cultures are indicated, ensure adequate volume collected (see Additional notes below)
Antimicrobial recommendations may vary according to local antimicrobial susceptibility patterns; please refer to  local guidelines
(https://www.rch.org.au/clinicalguide/guideline_index/Local_Antimicrobial_Guidelines/)

Infants ≤ 28 days corrected age

Assess promptly for signs of sepsis and discuss with a senior doctor. See Recognition of the seriously unwell neonate and young
infant (https://www.rch.org.au/clinicalguide/guideline_index/Recognition_of_the_seriously_unwell_neonate_and_young_infant/)
FBE, CRP, blood culture, urine (by SPA; see section on Urine collection below for other methods), LP ± CXR
Prompt treatment with empiric antibiotics (https://www.rch.org.au/clinicalguide/guideline_index/Antibiotics/)
If the infant appears unwell, or there is likely to be a delay in completing all of the required investigations, proceed with
administration of antibiotics

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Infants 29 days to 3 months corrected age

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Children >3 months corrected age

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Consider consultation with local paediatric team when

Unwell child
Septic shock
Infants <28 days corrected age with fever (should be admitted for empiric antibiotics)
Barriers to follow-up within 24 hours due to social or external factors (consider admission)
High-risk child
Advice needed regarding empiric treatment
Prolonged fever of unclear cause

Consider transfer to tertiary centre when

Child requiring care above the level of comfort of the local hospital

For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER)
Service: 1300 137 650

Consider discharge when

Infants 29 days to 3 months of corrected age: well, investigations normal, discussed with senior doctor, follow-up within 12-24
hours has been arranged
Children >3 months corrected age: well, follow up has been arranged
Always advise parents to return for review if the child is deteriorating

Parent Information
Fever in children (https://www.rch.org.au/kidsinfo/fact_sheets/Fever_in_children/)

Additional resources
Fever in under 5s: assessment and initial management. (https://www.nice.org.uk/guidance/ng143/ ) NICE guideline 2019

Additional notes
Temperature measurements
Axillary temperature: recommended for infants <3 months of age
For a more accurate reading, the thermometer should be placed over the axillary artery for 3 minutes.
Tympanic temperature: recommended for children >3 months of age. For an accurate measurement, the pinna must be retracted
to straighten the external auditory meatus and the instrument should be directed at the tympanic membrane.
Skin temperature: forehead or infrared thermometers are unreliable
Rectal temperature: in neonates, screen first with axillary temperature, then consider performing a rectal temperature if a fever is
still suspected

Lumbar puncture
When indicated, LP should be performed without delay and, ideally, before the administration of antibiotics
Contraindications to LP include impaired conscious state, focal neurological signs, impaired coagulation or haemodynamic
instability

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Clinical Practice Guidelines : Febrile child 8/5/23, 22:39

In this circumstance, treatment for meningitis/encephalitis should be commenced and an LP performed when the child is stable
and there are no contraindications
See Lumbar puncture (https://www.rch.org.au/clinicalguide/guideline_index/Lumbar_puncture/)

Urine collection
Bag urine specimens should never be sent for culture due to high false positive rates - contamination rate 50%
Suprapubic aspirate (see  SPA (https://www.rch.org.au/clinicalguide/guideline_index/Suprapubic_Aspirate_Guideline/)): gold
standard - contamination rate 1%
In/out catheter: useful if there is little urine in the bladder, such as after failed clean catch or SPA (discard first few drops of urine if
possible to reduce contamination) - contamination rate 10%
Midstream urine (MSU): preferred method for toilet-trained children who can void on request - contamination rate 25%
Clean catch: appropriate for pre-continent children who cannot void on request, but are not seriously unwell (yield may be
improved by gently rubbing child’s suprapubic area with gauze soaked in cold fluid, see  urine tests
(https://www.rch.org.au/kidsinfo/fact_sheets/Urine_tests/)) - contamination rate 25%

The perineal/genital area should be cleaned with saline-soaked gauze for 10 seconds before collecting midstream or clean catch urine

See Urinary tract infection (https://www.rch.org.au/clinicalguide/guideline_index/Urinary_Tract_Infection_Guideline/)

Blood culture
Blood cultures should be taken using an aseptic technique and sterile gloves
Accuracy of blood culture results rely on correct blood volume to improve detection of bacteraemia or fungaemia
Inoculate aerobic bottle preferentially, ie if inadequate volume for both bottles

Volume and type of blood culture:

Paediatric aerobic bottle Adult aerobic bottle Adult anaerobic bottle

Weight (for small volumes)

Min vol: 0.5 mL Min vol: 5 mL

Max vol: 4 mL Max vol: 10 mL

<1.5 kg 1 mL N/A (unless specific clinical indication)

1.5-5 kg 1.5 mL

5-10 kg 3 mL 5 mL

11-15 kg 4 mL 5 mL

16-20 kg Use green bottle whenever 6 mL If anaerobic BC 6 mL

>4 mL collected not indicated, put
10 mL in aerobic
21-25 kg 8 mL 8 mL
bottle

>25 kg 10 mL 10 mL

Last update September 2022

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 Reference List

1. Alejandre C, Guitart C, Balaguer M, Torrus I, Bobillo-Perez S, Cambra FJ, et al. Use of procalcitonin and C-reactive protein in the
diagnosis of bacterial infection in infants with severe bronchiolitis. European Journal of Pediatrics. 2021;180(3):833-42.
2. Biondi EA, Lee B, Ralston SL, Winikor JM, Lynn JF, Dixon A, et al. Prevalence of Bacteremia and Bacterial Meningitis in Febrile
Neonates and Infants in the Second Month of Life: A Systematic Review and Meta-analysis. JAMA Network Open.
2019;2(3):e190874.
3. Bonadio W, Huang F, Nateson S, Okpalaji C, Kodsi A, Sokolovsky S, et al. Meta-analysis to Determine Risk for Serious Bacterial
Infection in Febrile Outpatient Neonates With RSV Infection. Pediatric Emergency Care. 2016;32(5):286-9.
4. Craig JC, Williams GJ, Jones M, Codarini M, Macaskill P, Hayen A, et al. The accuracy of clinical symptoms and signs for the
diagnosis of serious bacterial infection in young febrile children: prospective cohort study of 15 781 febrile illnesses. BMJ.
2010;340:c1594.
5. Dodd SR, Lancaster GA, Craig JV, Smyth RL, Williamson PR. In a systematic review, infrared ear thermometry for fever diagnosis
in children finds poor sensitivity. Journal of Clinical Epidemiology. 2006;59(4):354-7.
6. Elkhunovich MA, Wang VJ, Pham P, Arpilleda JC, Clingenpeel JM, Mansour K, et al. Assessing the Utility of Urine Testing in
Febrile Infants 2 to 12 Months of Age With Bronchiolitis. Pediatric Emergency Care. 2019;03:03.
7. Fever in under 5s: assessment and initial management. NICE guideline 2019. https://www.nice.org.uk/guidance/ng143
(https://www.nice.org.uk/guidance/ng143) (viewed 5th September 2022).
8. Gomez B, Mintegi S, Bressan S, Da Dalt L, Gervaix A, Lacroix L, et al. Validation of the "Step-by-Step" Approach in the
Management of Young Febrile Infants. 2016.
9. Hsiao AL, Baker MD. Fever in the new millennium: a review of recent studies of markers of serious bacterial infection in febrile
children. Current Opinion in Pediatrics. 2005;17(1):56-61.
10. Irwin AD, Wickenden J, Le Doare K, Ladhani S, Sharland M. Supporting decisions to increase the safe discharge of children with
febrile illness from the emergency department: a systematic review and meta-analysis. Archives of Disease in Childhood.
2016;101(3):259-66.

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