The Pyrexial Child 

in primary care setting

Dr Hassan DawoodSHO GP

Structure of the Presentation

How to measure T? Causes of pyrexia in childhood Assessment (Traffic Light System) Signs & symptoms Specific diseases

 Management Antipyretics Management by the paediatric specialist 

How To Measure T?NICE Guidelines ( < 5 yrs )

 

DON'T : ( ORAL / RECTAL ) ROUTE

- < 4 wks: electronic thermometer in the axilla - 4  wks - 5 yrs: • electronic thermometer in the axilla • chemical dot thermometer in the axilla • infra-red tympanic thermometer

 - Parental perception

Causes Of Pyrexia In Children

I - C - C - R - Ex - ++

• Infections • Convultions  * <===>• CA• Rheumatoid• External factors• Over dressing

Assessment

Level of Risk ( Traffic Light System)

  • ABCD inc CR ( + T ) ? DEFG

 • Hx / Ex:

o ? Abroado ? Source o ? Specific signs & Symptoms

 • ? Infection screen

 

Colour

 

Activity

 

Respiratory

 

Hydration

 

Other

 

Herpes Simplex Encephalitis

Meningitis, Meningococcal Dis

Pneumonia

Kawasaki disease

UTI

Septic arthritis/osteomyelitis

• Neck stiffness • Bulging fontanelle • level of consciousness 

Non-blanching with 1 or more: • an ill-looking child • larger than 2 mm in diameter • CRT ≥3 seconds • neck stiffness

Fever >5 days & 4 of the following: • bilateral conjunctival inj• change in URT mucous membranes (eg, injected pharynx, dry cracked lips or strawberry tongue) • change in the periph extremities (eg,oedema, erythema or desquamation) • polymorphous rash • cervical lymphadenopathy

• Focal neur signs/ fits• level of consciousness

• Tachypnoea    0–5 m – RR > 60 b/m     6–12 m – RR > 50 b/m   > 12 m – RR > 40 b/m• Crackles, Nasal flaring, Chest indrawing,     Cyanosis • Sats ≤95%

(> 3 months)• Poor feeding, Vomiting, Lethargy, Irritability, Abdo pain • Frequency or dysuria • Offensive urine or haematuria

• Swelling of a limb or joint

• Not using an extremity • Non-weight bearing

+ FEVER

ManagementGREEN ( LOW RISK ) Manage at home with advice: • Antipyretic• Hydrate ++ (if breastfeeding to cont as normal)• Off school/ nursery • When to seek help:

o Signs of dehydration :  fontanelle, eyes, tears, mouth, overall

appearenceo Non-blanching rash (glass test)o Fitso Parents ditress/ concerno Fever >5 days

Management

AMBER ( INTERMEDIATE RISK )

Provide parents / carers with a safety net:• Verbal ± written info re warning symp• How to access further healthcare / Liaise on with out

of hrs• ? F/U

RED ( HIGH RISK )

Ref urgently to Paeds

Further  Invx & Management

● Test fo UTI ● If pneumonia is suspected but the child has not been referred to hospital, do not routinely perform CXR

● Do not prescribe oral ABx to a child with fever without apparent source

● If meningococcal disease is suspected, give parenteral ABx ASAP (benzylpenicillin or a third-generation cephalosporin)

Antipyretics● Tepid sponging is not recommended. ● Do not over or under dress a child with fever.

● Consider either paracetamol or ibuprofen as an option if the child appears distressed or is unwell. ● Do not administer paracetamol and ibuprofen at the same time, but consider using the alternative agent if the child does not respond to the first drug.  ● Do not routinely give antipyretics with the sole aim of reducing body temperature.  ● Do not use antipyretics with the sole aim of preventing febrile convulsions.

Management by the paediatric specialist

● Children with fever without apparent source presenting to paediatric specialists with one or more ‘red’ features should have the following investigations performed: – FBC– BC – CRP – urine testing for UTI.

● The following investigations should also be considered in children with ‘red’ features, as guided by the clinical assessment: – LP in children of all ages (if not contraindicated) – CXR irrespective of body temperature & WCC– U+Es & BG

Structure of the Presentation

How to measure T? Causes of pyrexia in childhood Assessment (Traffic Light System) Specific signs & symptoms specific diseases

 Management Antipyretics Management by the paediatric specialist