Febrile Child Assessment and Management

This guideline provides evidence-based recommendations for the assessment and management of febrile children in emergency and primary care settings.

Overview

Fever is one of the most common presenting complaints in pediatric emergency departments and primary care settings. This guideline aims to:

Standardize the approach to febrile children
Identify high-risk patients requiring immediate intervention
Provide clear management pathways
Reduce unnecessary investigations and treatments

Initial Assessment

Red Flags - Immediate Medical Attention Required

If any red flags are present:

Immediate medical assessment is required
Consider activating emergency protocols based on local guidelines
Prepare for potential resuscitation if signs of shock or respiratory failure
Obtain urgent investigations including blood cultures before antibiotics if possible
Start empirical antibiotics without delay if sepsis is suspected

Age-Specific Considerations

Neonates (0-28 days)

Any fever in neonates requires urgent evaluation
High risk of serious bacterial infection
Consider sepsis workup and empirical antibiotics

Infants (1-3 months)

Fever without source requires careful evaluation
Consider Rochester or Philadelphia criteria for risk stratification
Low threshold for investigation and treatment

Children (3 months - 3 years)

Focus on clinical assessment
Consider urinary tract infection in this age group
Assess for signs of serious bacterial infection

Older Children (greater than 3 years)

Clinical assessment usually sufficient
Focus on identifying source of infection
Consider complications of common infections

Risk Stratification

Management Decision Pathway

Febrile Child Assessment Flowchart

graph TD
  A[Febrile Child] --> B{Age?}
  B -->|0-28 days| C[Full septic workup]
  B -->|29d-3m| D{Toxic or red flags?}
  B -->|Over 3 months| E{Toxic?}
  D -->|Yes| C
  D -->|No| F{Low-risk criteria?}
  F -->|Yes| G[Outpatient management]
  F -->|No| H[Admit for observation]
  E -->|Yes| C
  E -->|No| I{Source identified?}
  I -->|Yes| J[Targeted treatment]
  I -->|No| K{Risk factors?}
  K -->|Yes| L[Consider antibiotics]
  K -->|No| M[Symptomatic management]
  style C fill:#ffcccc
  style H fill:#ffffcc
  style L fill:#ffffcc

Swipe horizontally to view full diagram

Investigation Guidelines

Consider the following based on clinical assessment:

Urinalysis and culture: For all febrile children less than 2 years without obvious source
Blood cultures: For toxic-appearing children or those at high risk
Full blood count: If bacterial infection suspected
C-reactive protein: May help differentiate bacterial from viral infections

Based on clinical presentation:

Chest X-ray: If respiratory symptoms present
Lumbar puncture: If meningitis suspected
Stool culture: If gastroenteritis with blood/mucus

Management Pathways

Immediate Management

Assess airway, breathing, circulation
Obtain vital signs including accurate temperature
Perform focused physical examination
Identify red flags and high-risk features
Initiate appropriate investigations

Paracetamol: 15mg/kg every 4-6 hours (maximum 60mg/kg/day)
Ibuprofen: 10mg/kg every 6-8 hours (maximum 40mg/kg/day)
Avoid aspirin in children due to Reye's syndrome risk
Alternating paracetamol and ibuprofen may be considered for comfort

Consider empirical antibiotics for:

Neonates with fever
Toxic-appearing children
High-risk patients with suspected bacterial infection
Specific infections (UTI, pneumonia, etc.)

Common Empirical Regimens:

Age Group	First-line Therapy	Alternative
0-28 days	Ampicillin + Gentamicin	Cefotaxime + Ampicillin
1-3 months	Ceftriaxone	Ampicillin + Gentamicin
Over 3 months	Based on suspected source	Consider local resistance patterns

Discharge Planning

Advise parents to return if:

Child becomes more unwell
Fever persists >5 days
Poor oral intake or signs of dehydration
Rash develops
Breathing difficulties
Persistent vomiting
Parental concern

Arrange appropriate follow-up based on clinical assessment
Consider telephone follow-up within 24-48 hours
Ensure results of investigations are followed up
Provide clear written information

Special Considerations

Occur in 3-5% of children aged 6 months to 5 years
Usually benign but require assessment
Consider underlying cause of fever
Provide parental education and reassurance

Simple Febrile Seizure Criteria:

Duration less than 15 minutes
Generalized (not focal)
No recurrence within 24 hours
Complete recovery

Consider in children with:

Fever >5 days
Conjunctivitis
Rash
Lymphadenopathy
Mucositis
Extremity changes

Management:

Early treatment with IVIG reduces risk of coronary artery aneurysms
Consult with pediatric specialist
Echocardiogram recommended

High index of suspicion for:

Rapid onset of illness
Petechial/purpuric rash
Shock
Altered consciousness

Management:

Immediate empirical antibiotics
Aggressive fluid resuscitation if shocked
Consider steroids based on local guidelines
Public health notification required

Quality Indicators

Process Indicators

Time to triage assessment
Appropriate use of investigations
Antibiotic prescribing rates
Documentation of safety net advice

Outcome Indicators

Representation rates within 48 hours
Admission rates
Length of stay
Patient/parent satisfaction

References

National Institute for Health and Care Excellence. Fever in under 5s: assessment and initial management. NICE guideline [NG143]. 2019.
Australian and New Zealand Paediatric Emergency Medicine Research Network. Clinical practice guideline for the management of fever in children. 2018.
Baraff LJ. Management of fever without source in infants and children. Ann Emerg Med. 2000;36(6):602-614.

This guideline should be used in conjunction with clinical judgment and local protocols. Regular review and updates are essential to maintain currency with best practice.