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Acute febrile illness in children


Childhood fever could not be more common – and therein lies the risk says GP and medico-legal expert Dr David Willox


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EWGPs will have not at some time experienced anxiety and diagnostic uncertainty when faced with an ill and feverish child. Te vast majority of childhood fevers are self limiting, usually viral in origin, and do not require much intervention other than analgesia, fluids and parental support. But rarely there may be severe underlying illness such as septicaemia. Longer lasting, relapsing fever may also be associated with very rare conditions, such as Kawasaki disease. The GP needs to see such patients promptly, make a safe diagnosis and take appropriate action to identify any more serious underlying disease. This can be a difficult task and calls for some degree of organisation in approach and calm assessment of the child and (often) their parents.


GPs may readily differentiate the clearly very ill, high-risk child from the relatively well, low-risk child. Of greater concern can be those children who are not sufficiently ill to require admission to hospital but nevertheless show signs which raise concerns as to their overall risk. Te NICE guidance, Feverish illness in children:


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Assessment and initial management of children younger than 5 years, provides some useful guidelines.


History and examination Nothing beats a careful history. In young children this is almost always via the parent and means exploration of the course of the illness. Careful record keeping is essential. Vomiting which has lasted three days, six or eight times a day, is clearly different to a single episode five days ago, yet oſten such details are not recorded. Listening to the parent’s account provides invaluable insight into the history as well as the parent’s concerns and ability to cope.


When assessing a child with fever the doctor should measure and record: • temperature • heart rate • respiratory rate • capillary refill time.


Irrespective of history it would also be usual to examine the ENT, chest, abdomen and skin, recording that this had been done and relevant findings.


A raised heart rate and capillary refill


time of greater than three seconds in children with fever can be a sign of serious illness, particularly septic shock. In children younger than three months a temperature of over 38° Celsius should be considered high risk, and the same should be said of children with a temperature of 39° or higher between three to six months of age. Apart from this, body temperature alone should not be used to identify children with serious illness nor should the duration of fever.


It is also important that children who have fever should be assessed to eliminate the possibility of dehydration. Common signs include abnormal skin turgor, abnormal respirations, weakness or rapidity of the pulse, cool extremities and prolonged capillary refill time. In severe situations dry mucous membranes may be noted along with a history of reduced or absent micturition.


Assessment


NICE guidelines set out three categories which help to define high, intermediate or low risk for serious illness. Tese are summarised in the table opposite.


SUMMONS


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