People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care. Show
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding. 1.1 Thermometers and the detection of feverOral and rectal temperature measurements1.1.1 Do not routinely use the oral and rectal routes to measure the body temperature of children aged 0 to 5 years. [2007] Measurement of body temperature at other sites1.1.2 In infants under the age of 4 weeks, measure body temperature with an electronic thermometer in the axilla. [2007] 1.1.3 In children aged 4 weeks to 5 years, measure body temperature by one of the following methods:
1.1.4 Healthcare professionals who routinely use disposable chemical dot thermometers should consider using an alternative type of thermometer when multiple temperature measurements are required. [2007] 1.1.5 Forehead chemical thermometers are unreliable and should not be used by healthcare professionals. [2007] Subjective detection of fever by parents and carers1.1.6 Reported parental perception of a fever should be considered valid and taken seriously by healthcare professionals. [2007] 1.2 Clinical assessment of children with fever1.2.1 First, healthcare professionals should identify any immediately life‑threatening features, including compromise of the airway, breathing or circulation, and decreased level of consciousness. [2007] 1.2.2 Think "Could this be sepsis?" and refer to the NICE guideline on sepsis: recognition, diagnosis and early management if a child presents with fever and symptoms or signs that indicate possible sepsis. [2017]Sepsis is a condition of life-threatening organ dysfunction due to a dysregulated host response to infection. Assessment of risk of serious illness1.2.3 Assess children with feverish illness for the presence or absence of symptoms and signs that can be used to predict the risk of serious illness using the traffic light system (see table 2). [2013] 1.2.4 When assessing children with learning disabilities, take the individual child's learning disability into account when interpreting the traffic light table. [2013] 1.2.5 Recognise that children with any of the following symptoms or signs are in a high-risk group for serious illness:
1.2.6 Recognise that children with any of the following symptoms or signs are in at least an intermediate-risk group for serious illness:
1.2.7 Recognise that children who have all of the following features, and none of the high- or intermediate-risk features, are in a low-risk group for serious illness:
1.2.8 Measure and record temperature, heart rate, respiratory rate and capillary refill time as part of the routine assessment of a child with fever. [2007] 1.2.9 Recognise that a capillary refill time of 3 seconds or longer is an intermediate-risk group marker for serious illness ('amber' sign). [2013] 1.2.10 Measure the blood pressure of children with fever if the heart rate or capillary refill time is abnormal and the facilities to measure blood pressure are available. [2007] 1.2.11 In children older than 6 months do not use height of body temperature alone to identify those with serious illness. [2013] 1.2.12 Recognise that children younger than 3 months with a temperature of 38°C or higher are in a high-risk group for serious illness. (Note that some vaccinations have been found to induce fever in children aged under 3 months.) [2013] 1.2.13 Recognise that children aged 3 to 6 months with a temperature of 39°C or higher are in at least an intermediate-risk group for serious illness. [2013] 1.2.14 Do not use duration of fever to predict the likelihood of serious illness. However, children with a fever lasting 5 days or longer should be assessed for Kawasaki disease (see the recommendation on additional features of Kawasaki disease in the section on symptoms and signs of specific illnesses). [2013, amended 2019] 1.2.15 Recognise that children with tachycardia are in at least an intermediate‑risk group for serious illness. Use the Advanced Paediatric Life Support criteria in table 1 to define tachycardia. [2013] Table 1 Advanced Paediatric Life Support criteria for tachycardia
1.2.16 Assess children with fever for signs of dehydration. Look for:
Symptoms and signs of specific illnesses1.2.17 Look for a source of fever and check for the presence of symptoms and signs that are associated with specific diseases (see table 3). [2007] Meningococcal disease and bacterial meningitisAlso see the NICE guideline on meningitis (bacterial) and meningococcal septicaemia in under 16s. 1.2.18 Consider meningococcal disease in any child with fever and a non‑blanching rash, particularly if any of the following features are present:
1.2.19 Consider bacterial meningitis in a child with fever and any of the following features:
1.2.20 Be aware that classic signs of meningitis (neck stiffness, bulging fontanelle, high-pitched cry) are often absent in infants with bacterial meningitis. [2007] Herpes simplex encephalitis1.2.21 Consider herpes simplex encephalitis in children with fever and any of the following features:
Pneumonia1.2.22 Consider pneumonia in children with fever and any of the following signs:
Septic arthritis or osteomyelitis1.2.24 Consider septic arthritis or osteomyelitis in children with fever and any of the following signs:
Kawasaki disease1.2.25 Be aware of the possibility of Kawasaki disease in children with fever that has lasted 5 days or longer. Additional features of Kawasaki disease may include:
1.2.26 Ask parents or carers about the presence of these features since the onset of fever, because they may have resolved by the time of assessment. [2019] 1.2.27 Be aware that children under 1 year may present with fewer clinical features of Kawasaki disease in addition to fever, but may be at higher risk of coronary artery abnormalities than older children. [2019] Imported infections1.2.28 When assessing a child with feverish illness, enquire about recent travel abroad and consider the possibility of imported infections according to the region visited. [2007]Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes. Table 2 Traffic light system for identifying risk of serious illness [2013]Refer to table 3 in the NICE guideline on sepsis if a child presents with fever and symptoms or signs that indicate possible sepsis. Children with fever and any of the symptoms or signs in the red column should be recognised as being at high risk. Similarly, children with fever and any of the symptoms or signs in the amber column and none in the red column should be recognised as being at intermediate risk. Children with symptoms and signs in the green column and none in the amber or red columns are at low risk. The management of children with fever should be directed by the level of risk. This traffic light table should be used in conjunction with the recommendations in this guideline on investigations and initial management in children with fever. A colour version of this table is available on the NICE tools and resources page.
Note that some vaccinations have been found to induce fever in children aged under 3 months. Table 3 Summary table for symptoms and signs suggestive of specific diseases [2013]
1.3 Management by remote assessmentRemote assessment refers to situations in which a child is assessed by a healthcare professional who is unable to examine the child because the child is geographically remote from the assessor (for example, telephone calls to NHS 111). Therefore, assessment is largely an interpretation of symptoms rather than physical signs. The guidance in this section may also apply to healthcare professionals whose scope of practice does not include the physical examination of a young child (for example, community pharmacists). Management according to risk of serious illness1.3.1 Healthcare professionals performing a remote assessment of a child with fever should seek to identify symptoms and signs of serious illness and specific diseases as described in the section on clinical assessment of children with fever and summarised in tables 2 and 3. [2007] 1.3.2 Children whose symptoms or combination of symptoms suggest an immediately life-threatening illness (see the recommendations on life-threatening features of illness in children) should be referred immediately for emergency medical care by the most appropriate means of transport (usually 999 ambulance). [2007] 1.3.3 Children with any 'red' features but who are not considered to have an immediately life-threatening illness should be urgently assessed by a healthcare professional in a face-to-face setting within 2 hours. [2007] 1.3.4 Children with 'amber' but no 'red' features should be assessed by a healthcare professional in a face-to-face setting. The urgency of this assessment should be determined by the clinical judgement of the healthcare professional carrying out the remote assessment. [2007] 1.3.5 Children with 'green' features and none of the 'amber' or 'red' features can be cared for at home with appropriate advice for parents and carers, including advice on when to seek further attention from the healthcare services (see the section on care at home). [2007, amended 2013] 1.4 Management by the non-paediatric practitionerIn this guideline, a non-paediatric practitioner is defined as a healthcare professional who has not had specific training or who does not have expertise in the assessment and treatment of children and their illnesses. This term includes healthcare professionals working in primary care, but it may also apply to many healthcare professionals in general emergency departments. Clinical assessment1.4.1 Management by a non-paediatric practitioner should start with a clinical assessment as described in the section on clinical assessment of children with fever. Healthcare practitioners should attempt to identify symptoms and signs of serious illness and specific diseases as summarised in tables 2 and 3. [2007] Management according to risk of serious illness1.4.2 Children whose symptoms or combination of symptoms and signs suggest an immediately life-threatening illness (see the recommendation on identifying life-threatening features) should be referred immediately for emergency medical care by the most appropriate means of transport (usually 999 ambulance). [2007] 1.4.3 Children with any 'red' features but who are not considered to have an immediately life-threatening illness should be referred urgently to the care of a paediatric specialist. [2007] 1.4.4 If any 'amber' features are present and no diagnosis has been reached, provide parents or carers with a 'safety net' or refer to specialist paediatric care for further assessment. The safety net should be 1 or more of the following:
1.4.5 Children with 'green' features and none of the 'amber' or 'red' features can be cared for at home with appropriate advice for parents and carers, including advice on when to seek further attention from the healthcare services (see the section on advice for care at home). [2007, amended 2013] Tests by the non-paediatric practitioner1.4.6 Children with symptoms and signs suggesting pneumonia who are not admitted to hospital should not routinely have a chest X-ray. [2007] 1.4.7 See the section on symptoms and signs in the NICE guideline on urinary tract infection in under 16s for when to test the urine of babies and children with fever for a UTI. [2007] 1.4.8 When a child has been given antipyretics, do not rely on a decrease or lack of decrease in temperature to differentiate between serious and non‑serious illness. [2017] Use of antibiotics by the non-paediatric practitioner1.4.9 Do not prescribe oral antibiotics to children with fever without apparent source. [2007] 1.4.10 Give parenteral antibiotics to children with suspected meningococcal disease at the earliest opportunity (either benzylpenicillin or a third‑generation cephalosporin). See the NICE guideline on meningitis (bacterial) and meningococcal septicaemia in under 16s. [2007] 1.5 Management by the paediatric specialistIn this guideline, the term paediatric specialist refers to a healthcare professional who has had specific training or has recognised expertise in the assessment and treatment of children and their illnesses. Examples include paediatricians, or healthcare professionals working in children's emergency departments. Children younger than 5 years1.5.1 Management by the paediatric specialist should start with a clinical assessment as described in the section on clinical assessment of children with fever. The healthcare professional should attempt to identify symptoms and signs of serious illness and specific diseases as summarised in tables 2 and 3. [2007] Children younger than 3 months1.5.2 Infants younger than 3 months with fever should be observed and have the following vital signs measured and recorded:
1.5.3 Perform the following investigations in infants younger than 3 months with fever:
1.5.4 Perform lumbar puncture in the following children with fever (unless contraindicated):
1.5.5 When indicated, perform a lumbar puncture without delay and, whenever possible, before the administration of antibiotics. [2007] 1.5.6 Give parenteral antibiotics to:
1.5.7 When parenteral antibiotics are indicated for infants younger than 3 months of age, a third-generation cephalosporin (for example cefotaxime or ceftriaxone) should be given plus an antibiotic active against listeria (for example, ampicillin or amoxicillin). [2007] Children aged 3 months or older1.5.8 Perform the following investigations in children with fever without apparent source who present to paediatric specialists with 1 or more 'red' features:
1.5.9 The following investigations should also be considered in children with 'red' features, as guided by the clinical assessment:
1.5.10 Children with fever without apparent source presenting to paediatric specialists who have 1 or more 'amber' features, should have the following investigations performed unless deemed unnecessary by an experienced paediatrician:
1.5.11 Children who have been referred to a paediatric specialist with fever without apparent source and who have no features of serious illness (that is, the 'green' group), should have urine tested for urinary tract infection and be assessed for symptoms and signs of pneumonia (see table 3 and the sections on urine collection, preservation and testing in the NICE guideline on urinary tract infection in under 16s). [2007] 1.5.12 Do not routinely perform blood tests and chest X-rays in children with fever who have no features of serious illness (that is, the 'green' group). [2007] Observation in hospital1.5.14 In children aged 3 months or older with fever without apparent source, a period of observation in hospital (with or without investigations) should be considered as part of the assessment to help differentiate non-serious from serious illness. [2007] 1.5.15 When a child has been given antipyretics, do not rely on a decrease or lack of decrease in temperature at 1 to 2 hours to differentiate between serious and non-serious illness. Nevertheless, in order to detect possible clinical deterioration, all children in hospital with 'amber' or 'red' features should still be reassessed after 1 to 2 hours. [2013] Causes and incidence of serious bacterial infection1.5.22 In a child presenting to hospital with a fever and suspected serious bacterial infection, requiring immediate treatment, antibiotics should be directed against Neisseria meningitidis, Streptococcus pneumoniae, Escherichia coli, Staphylococcus aureus and Haemophilus influenzae type b. A third-generation cephalosporin (for example, cefotaxime or ceftriaxone) is appropriate, until culture results are available. For infants younger than 3 months, an antibiotic active against listeria (for example, ampicillin or amoxicillin) should be added. [2007] 1.5.23 Refer to local treatment guidelines when rates of bacterial antibiotic resistance are significant. [2007] Admission to and discharge from hospital1.5.24 In addition to the child's clinical condition, consider the following factors when deciding whether to admit a child with fever to hospital:
1.5.25 If it is decided that a child does not need to be admitted to hospital, but no diagnosis has been reached, provide a safety net for parents and carers if any 'red' or 'amber' features are present. The safety net should be 1 or more of the following:
1.5.26 Children with 'green' features and none of the 'amber' or 'red' features can be cared for at home with appropriate advice for parents and carers, including advice on when to seek further attention from the healthcare services (see the section on advice for home care). [2007, amended 2013] Referral to paediatric intensive care1.5.27 Children with fever who are shocked, unrousable or showing signs of meningococcal disease should be urgently reviewed by an experienced paediatrician and consideration given to referral to paediatric intensive care. [2007] 1.5.28 Give parenteral antibiotics to children with suspected meningococcal disease at the earliest opportunity (either benzylpenicillin or a third‑generation cephalosporin). [2007] 1.5.29 Children admitted to hospital with meningococcal disease should be under paediatric care, supervised by a consultant and have their need for inotropes assessed. [2007] 1.6 Antipyretic interventionsEffects of body temperature reduction1.6.1 Antipyretic agents do not prevent febrile convulsions and should not be used specifically for this purpose. [2007] Physical interventions to reduce body temperature1.6.2 Tepid sponging is not recommended for the treatment of fever. [2007] 1.6.3 Children with fever should not be underdressed or over-wrapped. [2007] Drug interventions to reduce body temperature1.6.4 Consider using either paracetamol or ibuprofen in children with fever who appear distressed. [2013] 1.6.5 Do not use antipyretic agents with the sole aim of reducing body temperature in children with fever. [2013]
1.6.6 When using paracetamol or ibuprofen in children with fever:
1.7 Advice for home careCare at home1.7.1 Advise parents or carers to manage their child's temperature as described in the section on antipyretic interventions. [2007] 1.7.2 Advise parents or carers looking after a feverish child at home:
When to seek further help1.7.3 Following contact with a healthcare professional, parents and carers who are looking after their feverish child at home should seek further advice if:
Terms used in this guidelineThis section defines terms that have been used in a particular way for this guideline. For other definitions see the NICE glossary. FeverFor the purposes of this guideline, fever was defined as an elevation of body temperature above the normal daily variation. Which temperature method would not be preferred route to use on an infant?Mouth. Because a glass thermometer can break if a child bites down on it, this method is not recommended for children younger than 5 years old.
Which of the following is not a reliable method for taking a person's temperature quizlet?Which of the following is NOT a reliable method for taking a person's temperature? Using the forehead is the least reliable method for determining a patient's temperature.
In which of the following scenarios would an oral temperature method not be used with a patient?In which of the following scenarios would an oral temperature method not be used with a patient? The patient is an infant. Words such as normal, full or bounding, and weak and thread, describes which of the following words?
What special consideration is followed prior to measuring an axillary temperature?Place thermometer tip in the centre of the armpit over the axillary artery, ensuring skin is dry and intact prior to probe placement. Place the patient's arm securely against their body. Turn thermometer on. For a more accurate reading, wait >3 minutes with thermometer in situ before obtaining a measurement.
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