Red flag symptoms: Fever in children

Dr Lizzie Croton highlights what to look for in children with fever.

The first step is to ascertain how unwell the child is. Any non-blanching rash or a grey, unresponsive child should be treated as an emergency and go immediately to A&E.

Meningitis or septicaemia are the most important conditions to exclude. Septicaemia can be meningococcal or originate from another source such as the urinary tract.


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It is crucial to establish the fever source. Consider tropical diseases such as malaria.

Careful examination
Clues in the history such as ear pain, cough and sore throat may point to a URTI.

Any reported abdominal pain should prompt a thorough examination of the abdomen to exclude appendicitis and hernial orifices and genitalia in males to exclude a strangulated hernia or torsion. It is imperative to look in the ears and throat of every febrile child and listen to the chest to elicit the source of the fever.

A urine dipstick and MSU if positive may indicate a UTI. Children with a fever and no obvious focus of infection can be more difficult to manage.

If the child looks well, the fever can be controlled with antipyretics. Obtain a urine sample and review the child in 12 hours, if practical. If the child is unwell, not tolerating fluids and the fever is difficult to control, they should be referred to secondary care for further management. NICE guidelines on feverish illness in children and UTI in children are essential reading.

RED FLAG SYMTOMS

  • Rash
  • Unresponsive to treatment
  • Grey colour, floppy or reduced consciousness
  • Photophobia or neck stiffness
  • History of travel overseas Seeing a febrile child can be daunting, as a child with a high fever (38-39 degsC) can look quite unwell, be sleepy or have a rash.

When to medicate
Most children who are well with fever can be sent home providing the fever is <37 degs="" after="" medication="" but="" if="" there="" is="" any="" doubt="" ask="" for="" help="" from="" other="" colleagues="" p="">

Children with viral illness require antipyretics for the next three days and those with a bacterial infection require appropriate antibiotics.

Parents often need educating about not over-wrapping children with fever and giving appropriate doses of antipyretic to prevent sharp rise and falls of temperature.

Viral blanching rashes are also very common in children with fever and conditions such as roseaola but seek help if you are unsure. Safety-netting is imperative. Giving parents guidelines as to when to seek advice is empowering and may save lives.

  • Dr Croton is a salaried GP in Birmingham

Possible causes

  • Meningitis
  • URTI
  • UTI
  • Malaria
  • Inflammatory diseases.

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